Largest Donor Research Articles

Editorial: Can global health be good business?

A lavishly sponsored Global Health Summit conference in New York organized in early November by Time magazine included a panel discussion on the pertinent issue of whether global health can be good for business, and in the process highlighted many of the contradictions confronting health care providers, policy makers and planners the world over. Attempts to graft compassion onto the root stock of global capitalism have been only partially successful, if at all. Certainly none of the big players in the $3 trillion plus health care industry – whether they be pharmaceutical corporations, equipment manufacturers, hospital chains or health insurers – has been able to demonstrate any long term or sustained commitment to the delivery of health care services to the billions of people in low income countries who currently lack access to them. Many of the ‘Global Public Private Partnerships’ favoured by the WHO (Buse & Waxman 2001) appear to serve largely as public relations campaigns for the private sector ‘partners’ and also as a means to help them to secure and potentially expand their longer-term market for drugs and vaccines (Hardon 2000; Global Forum for Health Research 2002, 2004). Meanwhile some of the largest donors supporting such partnerships come from outside of the health care industry altogether – most notably Bill and Melinda Gates, whose benevolent billions also help make Microsoft’s cosmic profits seem more socially acceptable. Among those at the Time summit arguing that global health is, in fact, good business was Sir Richard Branson, chairman of another company outside of health care – the Virgin Group. He selected the example of yet another nonhealth business, Anglo-American, supplying anti-retroviral drugs to their staff in South Africa. As a result, instead of losing 25% of their staff from AIDS ‘they have got that 25% back in the mines, working and healthy’. Against the Branson approach, Prof. CK Prahalad from the University of Michigan argued that philanthropy can never ensure a sustainable future for health care systems, and that health care must develop as a business, down to the principle of charging even the poorest person for each item of treatment they receive. In one sense, Prof. Prahalad is obviously right: benevolence alone is not enough. Branson’s view of business supplying health care to ensure the continued productivity of its own direct workforce – similar to the US model in which General Motors is the country’s largest private health care purchaser (Lazarus 2005) – may, as Branson argues, be well in advance of the attitude of the majority of companies. But it offers only limited benefits in many of the poorest countries, where there are few if any wealthy companies able to make such choices, but where a large population of unemployed and desperately poor people stand outside the formal economy. Even in South Africa, a continental centre for global investment, half the population is poor, and 40% of the workforce is unemployed, and 60% of the unemployed have never worked. While some employers may be convinced to invest in their own workforce, there is little evidence that many companies can be persuaded to take an equivalent interest in the wider population, few of whom will be earning enough even to be potential customers. While the good intentions of a handful of benevolent and highly successful capitalists such as Branson and Gates are welcome, the capitalist system as a whole exists not to distribute goods or services to the needy, but to accumulate profit for proprietors and shareholders. The difficulty in translating this into the provision of global health care is that as a general rule those with the greatest health needs are poor people, who are least likely to be able to afford an economic price for their treatment. In other words, as even the World Bank’s researchers have concluded (Dunlop & Martins 1996), the laws of the market – which ensure that there is sufficient investment to present an abundance of consumer goods and services in the wealthier countries – collapse when applied to health care nationally and internationally. There is no mistaking the huge potential demand for health services, especially in the developing countries – but no section of the global

On Democratization and Peacebuilding

The two subfields addressed in this article did not exist twenty years ago. Scholars had only begun to analyze the beginnings of the third wave of democratization in the early 1980s, and the term peacebuilding only gained currency in the 1990s. By the early twenty-first century, the study of democracy and democratization had firmly become a subfield of political and sociological inquiry, as evidenced by the emergence of research centers and journals on the subject. Peacebuilding enjoyed a rapid rise, especially in policy circles, without the same degree of institutionalization. Nevertheless, it is surprising that international relations specialists only recently began to pay more rigorous attention to the relationship between peacebuilding and political governance and, more specifically, the extensive research on democratization. In this article, we analyze the relationship between these two growing subfields. (1) We highlight a central dilemma facing actors seeking to establish or improve postconflict governance. On the one hand, both the concepts and policies associated with international postwar political reconstruction have become broader, more sweeping, and more intrusive in recent years. The concept of peacebuilding now means not only keeping former enemies from going back to war, but also addressing the root causes of conflict and even fostering development in non-postwar societies. In practice, the international community is more bound and determined to create political regimes in postwar settings, recreating the core institutions of state and society largely along Western lines of thought. The largest donors and international organizations have coalesced around a standard postwar political package that Marina Ottaway calls the democratic reconstruction involving constitution making, elections within two ye ars of the end of hostilities, funding for civil society, and extensive state institution building. (2) The postconflict political agenda has very positive elements, especially as it signifies a departure from the great powers' persistent tendency to embrace dictators for strategic reasons. On the other hand, implementation of the prevailing democratic reconstruction has proven problematic. Of the eighteen single countries that experienced UN peacekeeping missions with a political institution-building component between 1988 and 2002, thirteen (72 percent) were classified as some form of authoritarian regime as of 2002.(3) The majority of these regimes represented clear improvements over their immediate predecessors but failed to meet the high expectations of international observers or local populations. The difficulties of postconflict democratization pose a number of questions. Do they signify a failure of the international community because of either insufficient resources or poor choices? Or are Western models of liberal democracy simply an inappropriate model? Conversely, should partial success be emphasized, recognizing that many years are required for consolidation and that expectations should be lowered? Some research shows that the international community appears unwilling to commit the economic, political, and military resources necessary to implement the model in any given society. Indeed, important research shows that applying the model, or misapplying it, can fuel setbacks to pluralism, such as armed conflict and even genocide.4 In this article we consider the implications of literature on democratization and peacebuilding for these questions. We argue that not only do peacebuilding and democratization specialists need to better learn from one another, but that improved outcomes are possible with greater resources, longer time horizons, and careful consideration of governance models in each case. The shortcomings of the reconstruction model require that more attention be paid to specific and local context and to integration of appropriate external governance models with local, legitimate practices in war-torn societies. …

Population Control is History: New Perspectives on the International Campaign to Limit Population Growth

The international campaign to control human fertility has inspired a vast inter-disciplinary literature, but only in recent years has it become a subject for historical study and debate. New archives have opened, especially among the largest donors during its early, heroic phase. And scientists and activists are increasingly willing to be reflexive about their lives' work. Most importantly, with rates of fertility declining in every region of the world, it is now possible to begin to see the end of the story. As the period of unprecedented growth in world population draws to a close, international efforts directed at limiting that growth—as opposed to safeguarding reproductive rights and health—will inexorably pass from the domain of policy to history.This distinction suggests the nature and limits of the term “population control,” which is itself fast becoming a historical artifact. As will be discussed anon, while it now denotes a shrinking subset of the “family planning” agenda, population control can be seen as encompassing the once wide-ranging efforts to shape the quality as well as the quantity of population. On this point see also Dennis Hodgson and Susan Cotts Watkins, “Feminists and Neo-Malthusians: Past and Present Alliances,” Population and Development Review 23 (1997):471. The latest U.N. projections are presented in “World Population Prospects: The 2000 Revision,” http://www.un.org/esa/population/wpp2000.html.

Small fish in a big pond? External aid and the health sector in South Africa

Since a new government was elected in 1994, South Africa has become a favoured nation for the many bilateral and multi-lateral agencies providing aid to developing countries. Despite several relatively large pledges of 'transition support', however, external resources constitute less than 2% of the annual government budget. This non-dependence has established a degree of equilibrium in a relationship normally regarded as highly unequal in other African countries. Although international donors funded the antiapartheid movement in South Africa prior to 1994, the new government inherited a chaotic administration that had little institutional experience of conventional development aid. Many of the new cadres entering government had not been exposed to the workings of government, let alone donor, bureaucratic processes. It is not surprising, therefore, that in the first few years after 1994, the aid relationship was characterized by low disbursements, unrealistic expectations and a degree of conflict. Since 1997, however, aid supported projects have started to become more visible. Within the broad objective of supporting transformation of the health system, one of the key areas of donor support is managerial capacity development, particularly of district, hospital and provincial health structures. These initiatives tend to be poorly coordinated, a problem compounded by a quasi-federal system in which provinces have large amounts of autonomy. The contribution of donor aid to strengthening the health system could be enhanced by the establishment of a clear national framework to guide the many externally supported projects building managerial skills and systems.

The foreign aid business: economic assistance and development co-operation

Offering an analysis of and development finance, this work examines the key issues and new trends in as well as proposing a series of improvements. Distinguishing clearly between aid and help in development finance, the authors discuss in the context of other North-South flows, such as trade or debt service, and describe its role and evolution during the Cold War. It addresses issues such as food aid, the European Union's Lome co-operation, Japan's emergence as the largest donor and its specific philosophy, the question of South-South aid, and the role of non-governmental organizations. The trends analyzed in the book include political conditionality, the UNDP's proposal to reorient towards human development and the question of diversion to the former communist countries. It concludes by proposing a series of reforms for development and finance. The authors advocate major improvements which include combining emergency and development aid, the financial accountability of donors, international insolvency to stop bailing-out creditors, and the emulation of the Marshall plan's self-monitoring by recipients.

International HIV and AIDS prevention: Japan/United States collaboration.

As the epicenter of the HIV/AIDS pandemic shifts from Africa to Asia, Japan is becoming ever more aware of the importance of containing and preventing spread of the virus. International collaboration, particularly with the United States, is a logical approach because it allows utilization of expertise from countries in other stages of the pandemic, can prevent duplication of efforts, and complements efforts of the other countries. Further, both Japan and the United States can use their combined influence and prestige to encourage cooperation among all nations. In 1994, Japan established the Global Issues Initiative to extend cooperation to developing countries in the areas of population and AIDS control. It has disbursed more than $460 million (U.S.$) to promote active cooperation and stimulate international attention to the importance of addressing these health issues. Japan has established four main programs for international collaboration for control of HIV and AIDS, three operated by ministries and one by a Japanese nongovernmental organization. Japanese/United States collaboration is developing through the United States/Japan Cooperative Medical Sciences Program, the Common Agenda for Cooperation in Global Perspective, the Paris Summit, and the United Nations Joint Programme on AIDS. It is critical that Japan and the United States, as the two largest donors to international development, demonstrate, through their collaboration, ways to maximize the use of limited resources, reduce duplication, and promote sustainable development programs in which HIV prevention and AIDS care programs are systemically integrated.

The Italian fight against world hunger. A critical analysis of Italian aid for development in the 1980s

During the 1980s, Italy expanded its development assistance, soon becoming the fifth largest donor. Italian development cooperation directed much effort to alleviate hunger, malnutrition and their health consequences. This paper provides an evaluation of Italy's fight against world hunger considering the political environment in which the policy was conceived and implemented, the organizational structure behind the policy, and the available quantitative indicators of outcome. The analysis shows how powerful humanitarian drives, supported by inchoate thinking about development problems and priorities, and by institutional and technical confusion, gave rise to development programs below accepted standards. Poor financial planning and the absence of proper mechanisms for project appraisal facilitated the capture of some programs by domestic political and commercial interests. In 1992, Italian magistrates began investigations into the extent of corruption in development assistance; preliminary reports documented widespread waste and ineffectiveness in major aid projects. Substantial changes in organization and priorities are needed in order to control past practices of corruption, improve the effectiveness of projects, and redirect Italian aid towards development goals.

Collaboration or Conflict? Foreign Aid and U.S.-Japan Relations

THE JANUARY 1989 announcement that Japan's ODA (Official I Development Assistance) disbursements would probably supersede U. S. foreign aid totals had been expected for at least two years. Ever since 1985, when Japan's aid doubling plans (begun in 1977) were boosted by the dramatic appreciation of the yen it was inevitable that the day would come when Japanese foreign aid superseded that of U.S. foreign aid, especially as the U.S. aid program was facing severe budget limitations. Japan has traveled a long road in a short time. Within days of the government's announcement that Japan would be the largest donor, Japanese television was reminding viewers that only twenty-five years ago the Shinkansen (bullet train) had been built just prior to the Tokyo Olympics as a World Bank project. The television programs also mentioned thatJapan was the second largest recipient, after India, of World Bank assistance at that time. In fact in 1990 Japan will finally be taken off the World Bank's borrower list by paying back its final installment. In other words in twentyfive yearsJapan had gone from being one of the largest receivers of foreign aid to becoming the largest donor of foreign aid. This change from recipient to the world's largest donor of foreign aid has also been mirrored in the overall U.S. -Japan relationship. Whereas twenty-five years ago Japan had a net trade deficit with the United States, today it enjoys an approximate $50 billion surplus. In 1964Japan's Self-Defense forces had a minor regional role in the Pacific but in 1988 Japan's defense budget appeared to be the third largest in the world after that of the U.S. and the Soviet Union. In part, Japan's rapid development is of course a direct result of America's calculated foreign policy following World War II. One of the underlying tenets of that policy was to create conditions for the promotion of economic development and democracy and by doing so to prevent, or at least minimize, the advance of Soviet-sponsored communism. Now,

External Funding for Population Programs In Developing Countries, 1982-1985

93% of the external assistance committed to population programs in developing countries comes from the public sector either directly from the governments of 17 developed countries (92%) or indirectly through the UNs membership assessments (1%). The private sector provides 7%. Population assistance ranged from $407 million in 1982 to $513 million in 1985. Adjusted for inflation population assistance has increased by an average of $2 million annually since 1971. The US commits more than $200 million annually to population programs approximately 60% of the total promised to developing countries. The next largest donor Japan provides 10%. However when country contributions are evaluated according to portion of gross national product the US and Japan are 6th and 9th respectively among the 17 donor countries. Norway commits almost 6 times the average for all countries/million dollars of gross national product; Sweden Denmark Finland and the Netherlands also rank above the average. Only about 1/3 of population aid goes directly from developed countries to developing countries through bilateral programs; another 1/3 flows through UN agencies and the remaining 1/3 is channeled through organizations in the private sector. Amounts actually disbursed to meet commitments over the 4 years ranged from $363 million to $483 million. The Asia and Pacific region has consistently received the largest amount followed by Latin America Africa and the Middle East. When the funding is calculated on a per capita basis however Latin America receives the most followed by Africa the Middle East and Asia. (authors) (summaries in SPA FRE)

THE NEED AND CRITERIA FOR THE SECTORAL PROGRAMING OF AUSTRALIAN AID TO PAPUA NEW GUINEA

The challenges posed by high balance of payments deficits that manifest as high saving-investment gaps in Papua New Guinea (PNG) are analysed. Foreign aid can play play a pivotal role to fill these balance of payments or savings-investment gaps. Australia as the largest donor of foreign aid to PNG is concerned about the need for the effective disbursement or programming aid. In this paper we demonstrate that using sectoral (bunch-criteria) based on the semi-input-output model provides a better framework for evaluating the effective performance of aid than programming aid to projects.