Easier Said Than Done (in Global Health): A Glimpse at Nonfinancial Challenges in International Cooperation

More attention should be paid to the consequences that the increasingly intricate panorama of international cooperation in health (ICH) has on low- and middle-income countries (LMIC), and the complex set of connections of decision-making processes, power relations, and global/local articulations involved in planning, channelizing, and executing international aid.  These notes aim to give a glimpse at some of the (nonfinancial) issues that the governments of LMIC confront in the process of incorporating technical and financial ICH in their national health agendas

Easier Said than Done (in Global Health): A Glimpse at Nonfinancial Challenges in International Cooperation


by Laura L. Nervi*

Adjunct Faculty at the Public Health Program of the University of New Mexico, USA

In the past decade, health has received a growing deal of attention in the international political agendas, and the funds disbursed for international cooperation in health (ICH) have nearly tripled.1  Accompanying this trend,   the corpus of analysis in several issues, such us financial flows, milestones declarations on aid effectiveness, and setting and monitoring of global health goals, has increased substantially.  However, less attention has been paid to the consequences that the increasingly intricate panorama of ICH has on low- and middle-income countries (LMIC), and the complex set of connections of decision-making processes, power relations, and global/local articulations involved in planning, channelizing, and executing international aid.  These notes aim to give a glimpse at some of the (nonfinancial) issues that the governments of LMIC confront in the process of incorporating technical and financial ICH in their national health agendas. Since the notes will underline general common challenges observed in ICH, crucial differences among countries will be overlooked and challengeable concepts will be used (for example, developed/developing), without referencing a specific donor, organization, country or region. 

 1.- Introducing International Cooperation in Health

Ideally, international cooperation in health (ICH) is the association among countries and/or their public and private institutions to mobilize technical (sharing know-how, best practices, and experiences), material and financial resources to reach common goals in the quest for social justice and health for all. ICH is also called global health aid, international health aid and development assistance for health. Though in these notes ICH will be used as a synonym for the other denominations, they have different underlying ideological assumptions. The concept of ICH emphasizes “…a joint effort integrating the partners in a process in which know-how and strategic orientations are shared, thus aiming at the joint planning and execution of programs or projects, with the autonomy of the partners and the sustainability of the process as a whole.”€2  The concepts of development assistance for health, global health aid, and international health aid evoke a vision based on a unidirectional, technology-transfer approach to aid, which was hegemonic among bilateral and multilateral agencies from the forties to the late seventies.3  

ICH is a large piece of overall development aid. In the year 2012 alone, it accounted for an estimated 28.1 billion dollars in loans and non-reimbursable funds for health.4  ICH plays an important role in many LMIC. In some low-income countries, ICH is a crucial complement, although always subsidiary to government health expenditures. In 2010, for example, for all of Sub-Saharan Africa (the region where ICH has the greatest  significance), total government health expenditures reached 29.4 billion dollars, 3.6 times more than the ICH disbursed that same year in the area.  Although ICH is not a significant financial component of health spending in most middle-income countries, it often plays an important role, particularly in the area of technical cooperation. Moreover, a number of middle-income countries have become pivotal to triangular and South-South cooperation even while they still receive international aid. Altogether, LMIC government health expenditures are more than 18 times the funds disbursed in ICH (in 2010, 521 billion dollars for the former and 28.2 billion for the latter).5 

ICH (and all development cooperation) is an important part of the foreign policy (“€œnational interests”€) of donor countries.6  Sometimes, ICH policies change in the donor countries at the rhythm of the administrations and sometimes they stay the same. Some donor countries are greatly influenced by particular interests and lobbyists that pressure for specific ICH policies. South-South cooperation and trilateral cooperation are not exempt (at least by definition) to the potential influence of these forces. 

2.- A Changing Panorama and Challenges in ICH Governance

Assistance vs. Cooperation Models

Before neoliberal policies began to take hold about thirty years ago, ICH was mostly channelized through multilateral health organizations and bilateral agencies, which were (and still are) funded mostly with public resources. Multilateral agencies were mostly funded by the annual dues of their member countries and bilateral agencies were (and still are) funded by their countries ‘taxpayers’€™ money. Bilateral agencies and philanthropic and private funding always contributed to the multilateral system, which (at the time) would use the funds for multilaterally set priorities (although the private sector has always, in many ways, influenced the international health agenda). The one-country-member/one-vote system of governance in the multilateral system gave the developing countries at least a formal participation in the decision-making process.

Concerns with the efficacy of those agencies were raised by the donor countries and the academic world. They were sometimes blamed for their lack of expertise in expanding public health skills to attend the health needs of LMIC. Also, they were criticized for having the “€œideological imprint of the West,”€ developing a (paternalistic, preconceived, unidirectional, vertical) technology-transfer vision, showing a limited corporate memory, adopting untested policies that become unchallengeable doctrines, looking to satisfy their bureaucratic needs instead of the recipient countries’ needs, basing their cooperation activities mostly in meetings (the “workshop syndrome”) instead of more vigorous actions, and others.7  

The technology-transfer vision (called technical assistance) was challenged in the seventies by Halfdan Mahler and the movement he led for the democratization of WHO.8 They saw the asymmetrical power relations between donor and recipient countries and called for a shift from technical assistance to technical cooperation, something that other United Nations agencies were also discussing.9 10  Paulo Freire also influenced visions on cooperation, fighting the idea of prefabricated solutions as proper development instruments. He emphasized the importance of symmetrical relations between all the actors involved, one of his most famous statements being the following: “€œWe knew we had something to contribute to respond to that challenge. If not, there would be no reason to accept the invitation. But fundamentally, we knew that the help that was asked of us would only be true to the extent that, in the process, we would never pretend we were the exclusive subjects, reducing the role of the nationals who requested aid to pure objects. Authentic help  -this can never be said enough- is that in which all who are involved  help each other, growing together in the common effort of understanding the reality  they seek to transform. Only such a practice, in which those who give help and those who are helped simultaneously help each other, is the only kind in which the act of helping is not distorted into the dominance of those who help over those who are helped.”€11  

Cuba’€™s notion of ICH was influential in Latin America and Africa. It was the first country to develop what we today call South-South cooperation. Based on the principle of solidarity among peoples and the lessons learned through the building of its own public and universal national health system (despite the massive emigration of its doctors when the revolutionary government took office), Cuba started short and long-term cooperation in the early sixties. It developed one of the biggest ICH programs that included (and still includes) everything from humanitarian aid to the development of human resources, public health interventions, health services development, managerial capacities development, direct provision of health services and many other aspects of health. Cuba has proven that cooperation in health exceeds the form of direct financial support, garnering recognition and admiration for over 50 years of sustained work in most of the developing world. Today, ICH is one of its most important forms of diplomacy.12 

However, none of the models (assistance vs. cooperation) in ICH truly stood out or eliminated the other. Rather, they coexisted in bilateral and multilateral agencies and in NGOs and philanthropy-funded projects. As for the long-ago identified problems in the operations of bilateral agencies and multilateral health organizations, they were either overcome or  partially addressed by some agencies, or maintained or even deepened by others. Some of those problems were used as (for us, unacceptable) excuses to weaken the multilateral system instead of improving it, just as the national states’ weaknesses were used in most LMIC to impose structural adjustments in the eighties and other neoliberal policies in the nineties, and as the global financial crisis was recently used as an excuse to attack the universal social protection systems in Europe.

The Big Comeback of the Vertical Vision

Global governance and international cooperation started changing at a remarkable speed in the late  nineties in what has been called   the “€œemergence of private authority in global governance”€.13 Increasing proliferation of actors, fragmentation, “€œverticalization”€, and private authority have profoundly affected international development aid. It is important to note that this has transformed the way that conflicts of interest and public interest are seen.  UN agencies, governments, the private for-profit sector (including the pharmaceutical industry), the corporate philanthropic sector, business associations, and global non-governmental development organizations from developed countries, are all seen as equal “€œpartners”€ to share global health governance.14   

These changes also affected international health agencies in many ways and significantly weakened them. They are now severely underfunded and becoming host agencies, thus decreasing their ability to set up a countries-led agenda. Multilateral health agencies have been displaced (and their dependence on extra-budgetary and ear-market funds has climbed) and multilateral financial institutions have taken a leadership role in global health funding and policy-making, while bilateral agencies have raised their profile in developing countries.15  The philanthropic private sector has dramatically increased in its involvement with developing countries, either directly or through multilateral agencies, universities, or global NGOs. Since funding is voluntary, usually unpredictable and has high transaction costs, ICH has become more unstable.

The new ICH structure is characterized by a growing importance of health in the international political agendas combined with a rapid increase in funding for health16, but also by a proliferation of transnational actors at a global scale. Private players from developed countries have started directly influencing public policies in developing countries. New modes of association have become the new doctrine to fund and channelize aid, resulting in new global health initiatives, particularly public-private partnerships (PPP’€™s). PPP’€™s need quick results.17 They are unable and unwilling to pay enough attention to national capacity building and the strengthening of health systems. They do not integrate with ongoing horizontal processes, but rather tend to build up vertical structures. PPP’€™s and most global health initiatives focus on a disease, a group of diseases, or a special topic. In a 2007 study on 112 global health initiatives (that number must have grown by now), it was found that almost all initiatives invoked their intended contribution to the health-related MDGs. Looking at the initiatives’€™ primary purpose, an overwhelming number focused on infectious diseases, concentrating on either research and development of material health products (particularly drugs and vaccines) or on facilitating product access (especially to drugs and vaccines). On the other end, there were only two initiatives whose primary purpose was to contribute to the strengthening of health systems.18  

Developing countries are underrepresented in the board of directors of the new mechanisms of aid (PPP’€™s and other initiatives). Headquarters are set mostly in developed countries, and they are the ones who set the priorities and allocation of resources.19  

Beyond all, the common perception that private donors are sustaining ICH is mistaken. Private donors have an increasing importance in funding ICH, but taxpayers of developed countries are by far the main funders of the aid system. The visibility and influence of private actors in global health governance largely outweighs their monetary contribution. 

The unwanted negative results of some global health partnerships are only a part of the problem. The bulk of the issue is the progressive weakening (by reduced funding and leadership) of the multilateral system as an arena of international-policy setting and global coordination. 

Advances in the Discourse of the Difficult-to-fix World of Development Aid

Trying to deal with this setback in global governance and its potential negative influence on the fulfilling of the MDG’€™s, donors and aid recipients have taken firm steps to address development aid effectiveness. OECD states that, despite its large achievements, international development cooperation confronts serious challenges, such us lack of coordination, overly ambitious targets, unrealistic time and budget constraints, and political self-interest.20 The massive recognition of these problems resulted in a new set of principles to improve aid effectiveness. Since they were formulated, these principles have been adhered to by more than 100 countries. Four high-level forums have taken place in order to advance the aid-effectiveness agenda: the High Level Forum on Aid Effectiveness in Rome (2003)21, Paris (2005)22, Accra (2008)23, and Busan (2011).24 In 2011, a survey about the Paris Declaration, in which 78 countries participated, showed that some progress had been made, but overall, donors and LMIC fell short of the targets.25 In the area of ICH, the forums significantly impacted the discourse, and in a minor way, the actions of donors and the expectations of some LMIC. In addition, some initiatives and declarations emerged in the global health arena.26  

Despite the general consensus and the resources and energy invested in setting a different scenario for aid effectiveness, countries, in general, did not see their ICH problems solved. Furthermore, it is common that authorities and technical teams in the ministries of health of LMIC are not aware of the forums or how to benefit from the global commitments in place. 

What is clear is that there is a growing body of evidence that identifies major and unsolved problems in aid effectiveness. In 2004, Birdsall called them the “€œseven deadly sins on donor failings”€: 1) impatience with institution building, 2) pride (failure to exit), 3) ignorance (failure to evaluate), 4) sloth (pretending “€œparticipation”€ is sufficient for “€œownership”€), 5) envy (collusion and coordination failure), 6) greed (stingy, and worse, unreliable transfers), 7) foolishness (underfunding of regional public goods). Ten years later, despite global declarations, the landscape shows that (with some exceptions) the problems have deepened thanks to the big comeback of the vertical mindset.27 As Severino and Ray acknowledged in 2010, the Paris Declaration has various limitations. They raised four issues to characterize the problems that reduced aid effectiveness: a) marginal player syndrome (a product of the explosion in stakeholders of international cooperation that makes donors feel less and less responsible for the success or failure of their projects); b) diverging accountability syndrome (there are at least three coexistent systems of accountability in international cooperation policies: donors are accountable to recipient country’€™s governments, to the beneficiary population of the recipient country, and to the taxpayers of their own country and their representatives); c) evaluation gap syndrome (some actors are more effective than others but there is no way of establishing who is better than whom at doing what); d) the capacity-building paradox (the weaker the state capacities, the more donors tend to be massively present and design coordination mechanisms  that require high administrative capacities from the receiving state).28 Problems identified by Birdsall and Severino and Ray apply to the ICH field, particularly but not exclusively, in North-South cooperation. ICH, however, has specific determinants that make it one of the most difficult fields to approach.

The Specifics of Health in International Cooperation

Health may be very well, for many reasons, the most complicated component of the development cooperation arena. All cultures develop knowledges, practices and representations on the health-ill-care process and most produce authorized individuals to explain, care or decide on health-ill-related needs. So, there will always be one or more medical models to meet locally. With the expansion of capitalism, the western hegemonic medical model articulated with the local models and subsumed them, creating a complex stage that may be unique in every country/region.

Global expenditures in health are enormous; the health industry is one of the most profiting investment sectors and healthcare one of the most important employers. The medical-industrial complex interests (products, services and insurances) are at the root of today’€™s health systems in many developed and developing countries. Large portions of the population that only a few years ago were considered healthy are now being labeled with new “€œdiseases”€.  Pharmaceutical products are directly targeting the population, and enhancement drugs and procedures proliferate. It isn’t exactly the idea of a collective health/social medicine approach to spread this model in either the developed or the developing world.

In a world with appalling inequities (and health inequities are among the most evident), there are billions who do not have access to healthcare, medicines or basic public-health interventions. The discourse of ICH intends to address this situation, but there are at least three tensions that makes this difficult: the “€œimprint of the West”€ force that imposes aid priorities, mechanisms and tools to recipient countries (with few exceptions, ICH is still a donor-driven field), the universal and public health system model vs. segmented/fragmented and inequitable health systems models, and the technoscience-driven ICH vs. the right to health and a social justice based ICH approach.

Therefore, the debate on what ICH is really contributing begins long before an actual ICH policy is discussed. It starts by questioning what health system and social protection system is attainable by a country, and how to address the social determinants of health. It starts with understanding which actors (inside and outside governments) have already defined a horizon for building a public and universal national health system with the guarantee of extensive solidarity, integrality and quality. 

In health, there are also values dilemmas. One example in public health and particularly in women’€™s rights is the penalization of therapeutic abortion (induced abortion when the mother’s life is threatened). When a recipient country has changed its constitution to explicitly forbid all kinds of abortion, is it OK to overlook this? To what extent should ICH address it? In every country that penalizes therapeutic abortion, there is a women’€™s movement that fights and opposes the current legislation. How should cooperation organizations respond to the dilemma of supporting national policies while local women’s organizations are sometimes being persecuted because of this opposition? Where are the limits? What strategies should be developed with civil society, and which actors of civil society should participate? How is this related to the progressive call to untie aid? 

3.- Developing Countries Own (Health) Governance Capacity Challenges 

The governance capacity of the ministries of health (or the accumulation of institutional and personal competencies, abilities, vision, willingness, and commitment to build viability for the national health policy) is essential for an agenda of change.29 It is clear, however, that health ministries possess restricted power to single-handedly decide on the structure, healthcare models, or distribution of power within the health system they are supposed to lead.

Putting aside the lack of necessary financial resources, many LMIC have to confront serious governance issues. The stewardship of the ministries of health to lead the national health system may be weak, particularly in countries where the private sector is increasingly significant in the delivery of health services and products and/or in the selling of private health insurance. In highly segmented health systems, there are also challenges in regulating and monitoring the social security subsector (which could be composed of many independent entities) and the nonprofit sector (which may account for a large part of health coverage). Governance challenges may also be evident within the administration. Even in progressive administrations that recognize the importance of advancing public and universal health systems, it is not unusual for health ministers to have to make the case for health with the economic cabinet and, many times, with the presidential office. An equitable universal health system is not a concept that many would challenge today, but advancing an agenda based on the right to health implies many decisions that affect particular  interests, and various decisions within the presidential cabinet (to reallocate resources) that in many cases have not been foreshadowed during the previous political campaign. Proclaiming the right to health and being in a position to offer a comprehensive health system that honors that right are two different things. Somehow, ministers pay the price of this gap, even when they usually don’t participate in deciding how big an administration’€™s commitment will be to build a strong public-based health sector for all. In most cases, all they get is the power of deciding -€“with dramatically insufficient resources- upon how to improve health services for the poor. But as Richard Titmuss famously put it, “€œservices for the poor will always be poor services.”

Ministers of health have limited decision-making power in ICH, too.  In most cases, the amount of loans granted by the multilateral banks isn’€™t determined in the ambit of the ministry, under the (correct) principles that the national development model must be set at the presidential level and the economic cabinet has the mandate to consider both credit repayment possibilities and the implications of indebtedness. Often, however, the problem is that ministers of health are expected to fulfill the presidential agenda for building universal health systems with grossly insufficient resources and limited power to make the changes. Sometimes, they even see their ICH funds being diverted from their original purposes due to extra-sectoral pressures. Also, there are too many actors involved in the governance of ICH at the national level. Usually, several governmental entities participate in the negotiation and monitoring of ICH, such as foreign relations ministries, ministries of economy, planning secretaries and even the presidential office. It is not uncommon for some of them to become competing actors for international resources against the health sector while simultaneously supervising the canalization of aid to it. 

ICH funds are unpredictable. Under more regular circumstances, they are short-lived and with long periods of negotiation (multiannual projects are exceptions and not the norm). Thus, fear of losing resources is always central and increases dependency. In the midst of this, there is a generally accepted never-say-no attitude when it comes to accepting ICH. And if the national health authority rejects an offer for ICH, it is not unusual for some donors to knock on the door of other government officials in order to override the decision made in the health sector. 

4.- Dealing with ICH at the National Level

In dealing with ICH, many national teams find out that they are subjected to persistent stereotypes and oversimplifications by donors’€™ agencies. Among them are two easily identifiable ones. First are the “€œone size fits all”€ approaches that make the developing world a homogenous target of interventions. However, although they share common pressing issues, LMIC are not homogenous in their needs for ICH. Low-income countries share the burden of poverty and thus a common need for resources to confront their health problems and institutional capacity challenges, but they are not equal to even their own selves when different historical periods are considered, nor are middle-income countries, and neither are donors homogenous in their political and economic interests or priorities. 

Second, there is a problem with language (and its implicit assumptions) in international cooperation: the concept of “€œtechnical assistance”€ has been reenergized. While the Paris Declaration and other forums advanced concepts like “€œpartner countries”€, there are others ideas that contradict the advances. One example is the “€œgraduated country”€ concept. Although the notion of graduation was conceived to measure economic development for the least developed countries, it is now utilized by donor countries and aid institutions to evaluate how well a country has advanced in some health indicators and to justify the withdrawing of aid. Developing countries see this graduation topic as a penalization of their achievements and health gains, while most donors see this as a decent mechanism of accountability for the developed countries’ taxpayers who want to be reassured that their money is used where it is most needed. In any case, this concept shows that those who set the tests for graduation, the evaluators, and the decision-makers on aid allocation are from developed countries and so ICH is still based on their views, requirements and standards. 

Management (or the processes of dealing with ICH in the cycle of identification of resources and needs, through planning, channelizing, executing, monitoring/evaluating ICH related endeavors) is an important component of ICH for both the recipient countries and the donors. It accounts for a big part of lost resources because of the high opportunity costs on both donors’€™ and recipient countries’€™ sides, and for (most of) the delays in the execution of ongoing projects, which are one of the main problems identified by donor agencies in the area of health.

Ministries of health in the recipient countries have to deal with a plethora of poorly coordinated initiatives and actors with several (sometimes contradictory) agendas that pressure to fulfill deadlines: bilateral agencies, multilateral organizations for technical cooperation (several from UN, each with their owns goals and projects with the ministry of health)30, multilateral banks, universities, research institutions, medical missions and brigades of all kinds, diplomatic missions, global funds and global health initiatives, international NGOs, decentralized cooperation from donor countries (municipalities, regions and communities), corporate philanthropy,  pharmaceutical and technology companies that make donations, among others. In many cases though, ICH projects and funds aren’€™t even in the radar of the health national authority, and it is common for a big piece of ICH be unaccounted for (ministries may not be informed about projects developed at the local level or about projects with municipalities, NGOs or churches). 

There are also regulatory aspects. One of them is the often seen regulatory limbo for material donations (medicines, supplies and medical equipment) and medical missions. Sometimes regulations exist, but they are not enforced.  Some actors (including government officials) may want to channelize (and be recognized for) donations that do not pass the test for obsolescence or need. Sometimes, ministers of health have to accept all kinds of unapproved (and difficult to discard) donations of medical equipment, sometimes expired or out-of-the-list pharmaceuticals, and medical services for the sole reason that they have been given at no cost. 

Another issue is the clientelism that international agencies sometimes establish with their national focal points in a long partnership that is immune to changes in the health policy goals. Some donors see this as a guarantee for the continuation of projects at a ministerial level, but -€“besides the ethical component of favoritism and informal privileges that arise with it- clientelism obstructs cooperation with new goals that ministries may set.

Agencies need to execute their budget for ICH. Level of execution is one of the components of staff evaluation. So, when the end of the budgetary year nears, training activities, technical meetings, and other activities suddenly skyrocket. Opportunity costs aren’€™t estimated, and ministries and agencies very rarely measure the negative or positive impact of these activities on the performance of public health services (how many consults, surgeries, public health interventions were postponed or cancelled? how many health units or services were closed instead of open because of those activities?) and on the competencies of the health workforce.

Other problems are more closely related to procedural aspects of management. Among them is the contradiction between creating project implementation units and using national capacity. After the nineties, when multilateral banks created project implementation units, which often became virtually parallel ministries of health, many national and international actors called for a change. Although many donors (and also recipient countries) are still pushing to create or maintain project implementation units separate from the ministry, the Paris Declaration (reinforced by many donors) states that donors must respect national procedures and mechanisms that already exist in recipient countries. Therefore, using national procedures is a way to both recognize countries’€™ capacities and to strengthen management offices at the national level. The problem is that by doing so, donors sometimes idealize the capacities of national institutions to process (within very short time frames) acquisitions and services, which multiplies the workload of the national procurement offices. Only some of the agencies plan to provide resources to strengthen the procurement national capacity while executing the projects, and even fewer define time frames accordingly.

Other obstacles can be found in regard to aid instruments. Each agency has developed its own planning, monitoring and evaluation frameworks needed for accountability and project evaluation. The problem at the national level is that national teams have to manage dozens (if not hundreds) of different aid instruments that are not useful in monitoring the country’€™s own health policy, and on top of this, most of these instruments in ICH prioritize financial aspects, underplaying goal achievement. Proper instruments oriented to assess outcomes are scarce and the indicators are challengeable (many trying to measure outcomes in a unicausal, simplistic way). This is even more evident in the area of technical cooperation. Sometimes it seems as if some don’€™t want to truly know what is happening out of fear of potentially disappointing results. If evaluations and monitoring were oriented toward improving ICH quality (and not discrediting  underperformance), their role would be useful to identify and correct problems. And even though new planning instruments are labeled “€œstrategic planning,”€ “€œsituational planning”€ and so forth, it should be noted that many of them are just as rigid and normative as the traditional instruments. 

Finally, the tension between lengthy negotiations and recipient countries’€™ urgency to accomplish the goals of their health policies is a significant issue. Negotiating some projects can take two or more years. When resources come, competitive bidding and delivery times and services may add more. It is common for an  administration to spend more time negotiating ICH than using the resources. This, added to the problems of discontinuation of political and technical teams, high rotation rate of leaders, and changes in the health policy, puts the potential results of ICH at risk. 

5.- Building an ICH Country-led Policy at a National Level 

In a context of financially strained national health systems, health ministers that try to make the necessary changes toward universal coverage and health equity struggle to guarantee countless aspects of funds and governance, and to gain political support to make their case for health. Ministers have to strengthen governance capacities at leadership and institutional levels to develop stewardship within health systems that, in most countries, are fragmented and segmented (an uncoordinated combination of public, social security, private for-profit and nonprofit entities). They are also responsible for public health interventions and, usually, their mandate includes the direct provision of health services. Ministers are aware that health workers are the basis of the health system and that the shortage of health workers is one of the key limitations of success, and that a motivated workforce with the appropriate expertise in specific knowledges is crucial to run the system.31 And many ministers know that they (might) increase their chances to make a bigger difference by designing an ICH policy capable of mobilizing the maximum possible amount of technical and financial resources as well as partners, in support of the countries’€™ health priorities.

An ICH policy at the national level in a recipient country must be part of the national health policy and the strategic plan of the ministry of health, which must be aligned, at the same time, with the national development plan for a given governmental period. Also, an ICH policy is only part of a country’€™s international interests in health, which include a wide range of matters that are vital to gain health sovereignty, such as: health diplomacy as a component of foreign policy, health sector participation in negotiations of trade and investment agreements (those which have the potential to affect national health regulations), development of a body of research on consequences of international neoliberal policies on the health of the national population, proposing policies and  actions through the multilateral system, and monitoring execution of international mandates agreed upon by the country.

An ICH policy should contemplate governance aspects, such as: a) agreed upon mechanisms to hold donors and beneficiaries (including the ministry of health) accountable; b) all players involved in policy-making, mobilization and management of international resources should have a coherent vision and understanding of the priorities and goals of the health policy, as well as the strategies, priorities, and political agendas of international agencies and other donors; c) health ministries should  have the chance to exercise national stewardship in ICH, actively coordinating the negotiation and management components of ICH with the other governmental players involved, such us foreign ministries, planning secretaries, economic cabinet, and others; d) specific negotiations and agreements should be undertaken to avoid competition for international resources among different sectors of a same government, or different levels (local, regional, central) of the same sector; e) a body of evidence that documents how high the opportunity costs of ICH are at the national level  (including the processes of negotiation, execution, monitoring and evaluation of aid) and considers the possibility of rejecting some supply-led offers if the potential opportunity costs are higher than the aid itself, and if aid is tied to questionable goals or if national health sovereignty has been threatened; f)  LMIC also have things to offer, and have   developed competencies in a range of fields; an ICH policy should identify potential areas for technical cooperation with other countries through  South- South cooperation, trilateral cooperation, regional cooperation, and even  South-North cooperation (why not!).

An ICH policy should also identify specific strategies for resource mobilization and management. Among them: a) definition of a strategy to mobilize international resources aligned with the national health policy, its priorities and the strategic plan; b) mapping international financial and technical opportunities in detail and analyzing the antecedents of ICH with the country; c) assessment of gaps between the targets set by the ministry’s strategic plan and the available resources at national level, in order to orient ICH in filling those gaps; d)  a resource mobilization strategy that includes civil society organizations and intersectoral ventures; e) definition of a set of flexible mechanisms for monitoring and evaluating ICH aligned with the indicators defined by the health policy and, when possible, for utilizing national information systems (ICH to improve health information systems will always be welcome in most countries).

In addition, there are specific regulatory aspects at an ICH national-led policy level, such us the regulation of donations (medicines, medical supplies and medical equipment) and medical missions (that provide direct health services to the population or in association with governmental or non-governmental entities, or the ministry of health’€™s  health services), among many others. 

Definition and implementation of ICH policies based on social and international justice will always require strong political incidence initiatives aimed at generating public support in developed and developing countries in the hope to achieve less asymmetrical, more democratic, and equalitarian North-South relations –in order to make all actors accountable (including private actors), and to call for a shift from policies based on national interests or particular interests to cooperation policies based on the principle of solidarity among peoples.32 



I am very grateful to Anne-Emanuelle Birn and Celia Iriart for their timely suggestions on the contents and conceptualization of this paper.


1 IHME: Financing Global Health 2012: The End of the Gold Age?, University of Washington, Seattle, 2013. 

2 Buss PM, Ferreira JR: Critical essay on international cooperation in health. RECIIS -€“Eletr Rev of Com Inf Innov Health 2010, 4(1): p 87. 

3 Ferreira, JR: Estrategias internacionales en educacion medica: asistencia tecnica y cooperacion tecnica. Educacion Medica y Salud 1976; 10 (4): 335-344. 

4 This number accounts for the estimated development assistance for health for the year 2012 funded by national treasuries, debt repayments to international financial institutions, private philanthropists  and corporate donations, and channelized through  bilateral development assistance agencies, European Commission, UN agencies ( UNFPA, UNAIDS, WHO, UNICEF, PAHO) , World Bank and other regional development banks, The Global Fund to Fight AIDS, Tuberculosis and Malaria, GAVI Alliance, Foundations, and  International NGOs.  IHME: Financing Global Health 2012: The End of the Gold Age?, Seattle, Washington, 2013. 

5 Ib. 

6 Birn A-E, Pillay Y and Holtz T.: Texbook of International Health: Global Health in a Dynamic World. Oxford University Press, 2009, p 17-53. 

7 Foster, G.: Bureaucratic Aspects of International Health Agencies. Soc. Sci. Med.1987; 25 (9):1039-1048. 

8 Dr. Halfdan Mahler served three terms as director-general of WHO (1973-1988), and under his  leadership the €œ”Health for All by 2000″€ goal and the Primary Health Care strategy were launched. 

9 Mahler, H.: Shift for Technical Cooperation, WHO Journal, June 1976. 

10 UNITAR: The Search for New Methods of Technical Cooperation, Conference. Report No. 4, New York, 1974. 

11 Freire, P.: Cartas a Guiné-Bissau. Registros de uma Experiencia em Processo. Ed Paz e Terra, Rio de Janeiro, 1978, p. 8. 

12 Feinsilver, J.: “€œFifty Years of Cuban Medical Diplomacy: from Idealism to Pragmatism”€, in Krull et al (editors). Cuban Studies 41, University of Pittsburgh Press, 2010, pp. 85-104. 

13 Hall, R. and Biersteker, T.:The Emergence of Private Authority in Global Governance. Cambridge Studies in International Relations. London: Cambridge University Press, 2002. 

14 See STAKES inputs in this matter: Ollila, E.: Restructuring global health policy making: The role of global public-private partnerships. In Koivusalo, M. & Mackintosh, M. (Eds.),Commercialisation of health care: global and local dynamics and policy responses. Basingstoke: Palgrave, 2004.

Olilla, Eeva: Health-Related Public-Private Partnerships and the United Nations. In Global Social Governance. Themes and Prospects. Edited by: Bob Deacon, Eeva Ollila, Meri Koivusalo and Paul Stubbs Ministry of Foreign Affairs of Finland, 2004.

Olilla, Eeva:  Global health Prioritites: Priorities of the Wealthy?. GASPP, National Research and Development Centre for Welfare and Health, Helsinski, Finland. 2005. 

Also: Martens, J.: Multistakeholder Partnerships-Future Models of Multilateralism?. Dialogue on Globalization, Occasional Papers N29. Friedrich Ebert Stifung, Berlin, 2007. 

15 Global Health Watch: An Alternative World Health Report. Zed Books, London, 2011. P229-249. 

16 Development health aid had a moderate growth from 1990 to 2001 (it went from 5.7 billion dollars in 1990 to 10.8 billion dollars in 2001. In 2001 aid expanded quickly exceeding 11.2% on an annualized basis between 2001 and 2010 and almost tripled from 2001 (climbing to $28.2 billion in 2010). Due to the global financial crisis, aid stagnated: 28.1 billion dollars were disbursed in 2012, a 53 million dollars drop from 2010. IHME, Ib. 

17 Bull and McNeill analyze the emergence of GHPs and their concentration in product development and product access as associated with a series of factors. Among them are 1) the technological changes produced by the biotechnological revolution (that, on the one hand, affected negatively the development of impeded and developing market vaccines and drugs and, on the other hand, made vaccines and drugs more costly than before), 2) the restructure of the pharmaceutical industry in a few number of highly concentrated and also inter-cooperative companies (merges between research-based pharmaceutical industry and the takeover of the biotechnology companies by the pharmaceutical companies). For example, four companies account actually for over 75% of the world’€™s supply of vaccines , and 3) the changes in global health governance that include changes in leadership of the WHO and UN (with increasingly strained financial resources and an ideological change in the vision of who the partners are in the pursuit of Health For All), and a growing importance of private foundations in funding and advocating for specific health issues and technologies. Those factors resulted in the development of new mechanisms that were seen as convenient by all of the players involved. Bull, B. and McNeill, D. Development Issues in Global Governance. Public-Private Partnerships and Market Multilateralism. Routledge, London, 2007. 

18 Nervi, Laura: “€œMapping a Sample of GHI”€, PAHO/WHO, WDC, 2008. Report. 

19 Ib.

20 OECD: The High Level Forum on Aid Effectiveness: A History,http://www.oecd.org/document/63/0,3746,en_2649_3236398_46310975_1_1_1_1,00.html

21 Rome marked the moment in which for the first time principles of aid effectiveness were proclaimed in a declaration. Priority actions were identified: development assistance should be delivered based on the priorities and timing of the recipient countries, donor efforts should concentrate on delegating cooperation and increasing the flexibility of staff on country programs and projects, and good practices should be encouraged and monitored. 

22 Paris marked the first time that donors and recipients committed to work together and hold each other accountable. The Paris Declaration defines five principles on effective aid and lays out a  roadmap to improve the quality of aid. The principles are: ownership (developing countries set their own strategies for poverty reduction, improve their institutions and tackle corruption), alignment (donor countries align behind these objectives and use local systems), harmonization (donor countries coordinate, simplify procedures and share information to avoid duplication), results (developing countries and donors shift focus to development results and results get measured), and mutual  accountability (donors and partners are accountable for development results).

23 In Accra representatives of civil society added their voices. The Forum was oriented to try to  strengthen and deepen the implementation of the Paris Declaration. The Accra Agenda for Action (AAA) gives a roadmap to achieve Paris targets and gives an important role to capacity development.

24 In Busan non-traditional donors participated, recognized as the South-South cooperation providers (China, India and Brazil participated as providers in establishing commons principles alongside traditional donors). Busan calls for changes in the governance of the aid system. Paris principles are recovered and taken further: country-ownership (developing countries have to lead the process of setting development priorities); development results (keeping focused on the lasting impact of investments and efforts in reducing poverty, inequality and sustainable development, as well as capacity building); inclusive partnerships (establishing partnerships which have openness, trust and mutual respect, and acknowledging the complementary role of all actors in the partnership); and transparency and accountability (ensuring that this applies not only within the partnership but also in relation to the intended beneficiaries of development processes, such as the citizens, constituents and other stakeholders from donor and recipient countries). Busan also established a number of complementary actions on untying aid, predictability of development cooperation and use of country systems.

25 OECD: Aid Effectiveness 2005-10: Progress in Implementing the Paris Declaration, 2011.

26 These initiatives address the challenges in ICH directly or indirectly. Among the initiatives is the launch of the Global Health Workforce Alliance, created in 2006 as a common platform for action to address the crisis in human resources for health. The Oslo Ministerial Declaration of 2007 issued an  statement on global health as a pressing foreign policy issue (Ministers of Foreign Affairs of Brazil, France, Indonesia, Norway, Senegal, South Africa, and Thailand)..In 2010, the European Commission calls to gear up on health actions and, among other accounts, calls for establishing a more democratic and coordinated global governance. The International Health Partnership (IHP and later IHP+) created in 2007 explicitly approaches the topic of aid and aid effectiveness. IHP+ include international organizations, bilateral agencies and country governments that signed the IHP+ Global Compact to work to put internationally agreed principles for effective aid and development cooperation into practice in the health sector. Major results at recipient countries level are still to be seen.

27 Birdsall, N.:  Seven Deadly Sins: Reflections on Donor Failings. Working Paper 50. Center for Global Development, Washington DC, 2004.

28 Severino J-M and Ray O: “€œThe End of ODA II:  The Birth of Hypercollective Action”€, Working Paper Number 218, Center for Global Development, WDC, 2010.

29 Testa M. Decidir en Salud, Quién?, Como? y Por qué? Salud Colectiva. 2007;3(3):247-257.

30 Each UN agency deals independently with their national counterparts the execution of projects and resources. Although they  try to harmonize goals and actions through the United Nations Development Assistance Framework (UNDAF), their annual plans, negotiations and executions of resources are kept independent.

31 Crisp, N.:  Global health partnerships: the UK contribution to health in developing countries. DFID, London, 2007.

32 Political incidence is a set of “€œactivities aimed to increase access to/generate influence on the actors who have decision-making power in matters of importance for a group or for the society at large”.  Gibradze, N.: Evaluation of the RegionalProject on Political Analysis and Prospective Scenarios. Report. UNDP, 2012.


*Laura L. Nervi, born in La Plata, Argentina, holds a PhD in anthropology, a master’€™s degree in social sciences, another in public health, a bachelor’€™s degree in anthropology, and was also a resident of PAHO/WHO’€™s International Health Training Program. She has more than thirty years of experience in teaching, researching, mobilizing resources, and working with multi-disciplinary teams in managing technical/financial cooperation. Laura has worked in most countries of the Americas with governments, bilateral and multilateral agencies, universities, social movements, and NGOs, advocating for public and universal health systems and international cooperation policies based on the right to health. Currently, she leaves in Albuquerque and is an adjunct faculty at the Public Health Program (PHP) of the University of New Mexico, USA.