PHM-Exch> [PHM NEWS] GHW5 serialized summary (5)

[Claudio Schuftan]

For 6 weeks, the PHM-exchange will, on a weekly basis, bring you summaries
of all the chapters of its recently published Global Health Watch 5.   By
the time the last installment is sent out, PHM expects to be able to post
the full text of GHW5 electronically for your reading and perusal.
We encourage you to read, use and share this material since it provides
crucial advocacy contents.


*As in the case of all previous Global Health Watches, GHW5 does nothing
but build on PHM’s People’s Charter for Health launched in the year 2000. *

*All Watches tell activists worldwide what issues worry PHM and its
partners, why we denounce them, what consequences loom in the future if
nothing is done about them, what (if anything) is being done about them and
what actions PHM calls for and supports.*

*GHW5 presents to you a decisive global health critique and outlook not
easily found elsewhere.*



*D.    **WATCHING.*



*D1. MONEY TALKS AT THE WORLD HEALTH ORGANIZATION.*

WHO is beset with fundamental challenges that threaten the very foundations
and founding principles of the organization. Its capacity has been
seriously eroded over the years. Its legitimacy stands compromised.
Underpinning the deficiencies in WHO clearly is its funding crisis.

WHO’s budget is financed through a mix of extremely low assessed
contributions from member states and voluntary contributions/grants from
public and private sources. This gives the organization a chronic lack of
predictability it needs for its operations. Historically, the assessed
contributions exceeded voluntary sources of funding. Extra-budgetary
resources became the dominant source since the early 90s when assessed
contributions were frozen in 1993 by a resolution sponsored by the USA.  Let
it be mentioned that many member states have failed to pay their assessed
membership dues so that WHO is literally a financial hostage of voluntary
contributions that now make up about 80% of WHO’s total budget. These
contributions are overwhelmingly earmarked, i.e., tied to a particular
program. Just 7% of all voluntary contributions (by only 10 countries) have
lately been made as ‘core voluntary contributions’ that allow WHO to decide
its use. About half of the voluntary tied contributions has been from
countries (importantly the US and the UK) and the rest has been from other
donors including private foundations, inter-governmental agencies and
partnerships with private and corporate entities. None of the non-state
voluntary contributors provide untied core funds. Foundations like the
Gates Foundation have their favorite areas of support that ultimately guide
WHO’s recommendations. This begs the question: Are these partners or
competitors for health? The current model allows donors to finance and
deliver assistance in ways that they can more closely control and monitor
at every stage. Targeted donors influence not only results and give WHO
less flexibility; this also weakens support to WHO’s leadership that is now
driven by non-independent considerations thus undermining WHO’s ability to
use its expertise and full staff capacity. As a result, WHO has been more
vulnerable to influence by rich donor countries promoting the interests of
powerful corporations especially Big Pharma. This is how market power
readily translates into political power. This represents a failure of
political will of WHO to take-on big business. Clearly, donors are cherry
picking the areas they wish to fund.

Moreover, some WHO programs are grossly underfunded as a consequence of the
donor chokehold of its finances. Areas in which there is difficulty to
measure outcomes, irrespective of their public health importance receive no
support from donors. Similarly, the strengthening of health systems is
ignored by donors.  Do WHO priorities taken ‘under influence’ override
important decisions even taken by member states? Probably.

The consequences of all this go beyond global public health since WHO has
lost its political clout/importance relative to new actors in the global
health arena. The resulting shift in the governance influence additionally
pushes member states to engage in multistakeholder operations.

WHO’s Framework for Engagement with Non-State Actors (FENSA) has put
private sector entities on an equal footing with public interest entities,
not recognizing their fundamentally different nature and roles.

 When applied to major TNCs, their business associations and philanthropic
foundations, this FENSA categorization legitimizes the framing of public
health  problems *and* solutions in favor of the interests and agendas of
those actors. FENSA has also removed the existing restrictions on accepting
financial resources from the private sector to fund salaries of WHO staff
--a clear conflict  of interest (!).

For all the above reasons, there is an urgent need to reposition WHO as the
primary and central health authority and to break donor control plus
bringing the assessed contributions back as WHO’s core funding.
Contributions from non-state ‘partners’ must be accompanied with signed
agreements that guarantee commitment to UN standards and principles. FENSA
must be made to distinguish between non-state partners in general and
dominant donors. This makes PHM emphasize that the vicious circle whereby
current responses to the chronic financing situation are ac tually being
applied actually exacerbates it.

Xxx

*D2. PRIVATE PHILANTHROPIC FOUNDATIONS: WHAT DO THEY MEAN FOR GLOBAL
HEALTH? *

There is a growing influence of philanthropic foundations in global
development and the risk of side effects of this trend are being ignored.
Philanthropy is aimed at preserving rather than redistributing wealth. It
is an alternate notion of welfare embedded *within* the structure of
capitalism. These foundations are exempt from paying most taxes and
contributions to them benefit from tax deductions; up to a third or more of
their endowment monies are thus subsidized by public money. The Gates
Foundation important grant-making decisions are the purview of three people
(the trustees, i.e., Bill, Melinda and Warren Buffet). Philanthropy is
actually used to thwart demands for higher corporate taxation; in its
giving, it often opens up markets for US- or Europe-based multinationals.

However, a rosy picture of philanthropic engagement is still predominant as
the side-effects of their granting are still ignored. The SDGs do welcome
philanthropic engagement in multistakeholder partnerships with the private
sector; these are seen as ‘pragmatic’ and ‘solution-oriented’.

Philanthropy is growing, but only in the context of rampant inequalities as
they use market-based approaches to development. Almost all these
organizations attempt to influence decision-makers and to sway public
opinion.

They further give generous grants to the media --a clear conflict of
interest since the true debate about development is muffled whenever it
pertains to controversial issues.

They also get importantly involved in active political lobbing to foster
quick-win approaches while structural and political obstacles remain
neglected.

They have been rightly criticized for ‘managing the poor rather than
empowering them’.

Their reliance on technical solutions is well known; they thus love to fund
vertical disease-specific programs.

They foster the privatization of basic services silencing critiques when
these PPPs do not work.

They promote the notion that better technologies can offer lasting
market-based techno-solutions to the myriad complex global problems. For
instance, they ignore the necessity to build functional/functioning health
systems and to attend to the whole range of social determinants.

All are ‘searching for answers with their right hand to problems that
others in the room have created with their left’.

Governments are slowly realizing the risks associated with the growing
influence of corporate philanthropy though. They are slowly understanding
the risks of engagement with private actors and the possible safeguards
they need to put in place. They are too slowly coming up with the political
determination to effectively limit the influence of these philanthropies
though.

Note that WHO’s FENSA was crafted to accommodate private foundations and
for-profit entities. Their influence in WHO’s decision-making processes is
ignored rather than WHO effectively managing the serious conflict of
interest issues this raises.

There is, therefore, an urgent need for clear rules for cooperation with
private foundations with clear ‘red lines’ that will include minimum
requirements for such coop, as well as clear conflict of interest policies
and rules for transparency, accountability and independent evaluation.

CSOs must further reconsider their cooperation with philanthropic
foundations.

Xx

*D3. MANAGEMENT CONSULTING FIRMS IN GLOBAL HEALTH*

The role of management consulting firms has, by and large, remained hidden
from the public eye. Providing advice to governments around the world the
same way private corporations do was an idea whose time had come. These
firms share the belief that what the public sector needs is an injection of
private sector efficiency, cost effectiveness, project management skills
and monitoring frameworks: “We can show you how to run programs and how to
spend money, filling capacity gaps and reassuring boards of donors”.

Management consulting firms rapidly made themselves indispensible. Today,
they have become ubiquitous in global health institutions --becoming very
lucrative in the process.

The problem is that consultants have moved from providing organizational
advice to offering strategic guidance. There are thus questionable
implications of using these management consultants. This warrants
examination.

These consultants undermine systemic, root-causes interventions since they
tend to be generalists (and pride themselves to be such). They analyze
problems through an organizational management lens and use this as a basis
upon which their proposed responses to a problem are built. In our case,
this results in a tendency to collapse health and human development into a
technical exercise. This also means weeding out long-term solutions and not
focusing on the systemic dimensions of problems and their root causes
(e.g., discrimination, human rights, democratic participation, and power
issues). Such considerations are actually absent from consultants’
playbooks. Result? This entrenches the status-quo when it comes to systems
and power rather than challenging power. The consultants’ language includes
terms like ‘value for money’, ‘results-based financing’ and ‘high impact
interventions’ which push in the direction of the easier wins and ‘biggest
bang for the buck’, and not in the direction of the greatest needs. They
focus on ‘low-hanging-fruits’ and, in practice, this reduces support for
key prevention activities and reduces funding for organizing public
interest CSOs --if not undermining them!

All in all, consultants turn discussions on health into elite debates. This
changes the nature of activism and advocacy which are then filtered through
the efficacy model to health challenges. Public interest CSOs from the
South are consequently pushed to the margins.

Moreover, consulting firms consistently champion the public-private model
of cooperation as the quasi-universal solution. They are not bound to
disclose the names of their clients or the products or the analyses they
generate for them which are very seldom shared. In the case of WHO,
consultants hired by the Gates Foundation have gone as far as recommending
staff changes in the organization.

This opaque way of operating allows them to amass intelligence and
proprietary information. Predictably, this often leads to consultants being
hired time and time again on issues they have already worked-on without
them taking responsibility (or credit) for how their hiring institution
uses (or not) their advice. The impact of the recommendations they make is
rarely, if ever, evaluated!  …they have no commitment to the countries they
work in and much less connection with affected communities therein. Their
engagement has no accountability. Revolving door conflicts of interest are
not unheard-of in this business.

Management consultants forays into global health may be understood as
well-choreographed profit-seeking endeavors. Their engagement gets
translated into lucrative dependencies. They appear to have mastered the
art of socializing risks and privatizing benefits. The framing of health as
a technical exercise and the related focus on value for money, efficiency
gains and rapid results has led to the exclusion of those most
knowledgeable and those most in need, as well as led to   the side-lining
of systemic long-term solutions and to the downgrading of community voices.
Public interest is seldom served by the secrecy surrounding this business.

Xxx

*D4. GAVI AND THE GLOBAL FUND.*

Private actors appear to/or have hijacked both these partnerships in areas
of activities that are essentially public in nature. This is particularly
problematic given that both these partnerships are largely funded through
public sources --mainly through contributions from countries. Actually,
more than four fifths of all money for basic research to discover new
vaccines and medicines comes from public sources.

*The GAVI conundrum*: In its non-transparent decision making processes,
GAVI has a hybrid governance structure that involves non-state actors such
as pharmaceutical corporations. 79% of GAVI’s funding comes from
governments and the rest from foundations, corporations and individuals.
GAVI places emphasis on technological solutions to achieve quick,
short-term, quantifiable results.  In so doing, it promotes the interests
of private vaccine manufacturers. GAVI is known to accommodate the
pharmaceutical industry’s needs --basically, *four* multinational giants in
vaccine development and manufacturing that control almost 80% of the
vaccine market. GAVI does not promote local production and technology
transfers. It pushes national immunization schedules of countries it
supports that actually cost-share the vaccines they use.

Industry is further known to exaggerate their research and development
costs! For example, pneumococcal vaccine costs more than GAVI-eligible
countries can afford. Let alone, R&D activities would have paid off more if
focused on the real needs in these countries.

Charging different prices for the same product in different markets or
consumer groups allows Big Pharma to maintain market monopoly by blocking
generic competitors. Pricing decisions, we know, lack transparency
--nothing new here. Robust generic competition, and not tiered pricing,
offers the actual sustainable solution to this problem of higher prices of
new medicines and vaccines. Policies that encourage technology transfers
and that promote competition must thus be adopted --and these are not yet
part of GAVI’s strategy! Negotiations on these and other issues take place
in total darkness since the real costs of production are not known to the
negotiators.

Note that by 2025, 29 of the originally 73 eligible countries will have
lost GAVI support entirely and will have to fully finance their national
immunization programs.

 Given all this quasi-monopoly situation, MSF has, in protest, gone as far
as rejecting vaccine donations by Pfizer.

GAVI’s close association with the Gates Found raises further concerns
regarding conflict of interest.

Finally, only 10% of GAVI’s total commitments are dedicated to health
systems strengthening and that amount is, in big part, used to purchasing
boats, bikes, vaccination kits and cold chain equipment --all related to
immunization programs. GHW5 points out that GAVI’s support for other PHC
services is absent thus the persistent disconnect between immunization and
other aspects of the broader health system agenda. Bottom, line, GAVI’s
global immunization coverage has increased by only 1% since 2010.

*The Global Fund conundrum*: 93% of all Global Fund (GF) financing comes
from donor governments. The private sector’s influence on the GF is
disproportionately large compared to its 7% contribution.

WHO and UNAIDS have no vote on the board of the GF. Decision making is
entrusted to a small group of representatives with equal standing given to
the public and private sectors in its organizational governance. But the
public-private partnership character of it jeopardizes democratic global
governance.

The GF is not an inter-governmental organization. Nevertheless, all GF
grants are exempt from taxation.

The GF does not implement programs directly. With 700 staff based in
Geneva, it describes itself as a lean and efficient organization that does
not have country offices. It regularly offers opportunities and lucrative
contracts to the private sector. International management and auditing
firms are the ones that operate as GF agents (as fiscal agents and external
auditors). These firms consistently favor the local private sector to the
detriment of public health. They too often have negligible or limited
public health expertise, are expensive and offer services of questionable
quality. It is said they promote the ‘Gates approach’ to health governance,
clearly representing instances of private sector influence on activities
that are publicly funded and that essentially take place in the public
sphere.
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