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The PBF Toolkit: a neat contribution to the science of delivery

3/26/2014

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Designing and implementing a Performance Based Financing (PBF) scheme is an art. Isidore Sieleunou interviews an  artist who is happy that his latest piece of art finally saw the light : Gyuri Fritsche from the World Bank. Gyuri introduces the freshly released PBF Toolkit to us. You can access the full document here.

Could you tell us the main motivations that led to the production of this Toolkit? 

The main motivation for creating this toolkit was a sense that although there was a massive interest in PBF, the knowledge on PBF approaches was very limited and confined to a few early PBF pioneers. The idea was to make such knowledge which is based on years of experimentation, widely available to other experts. There was a sense (and such a sense still exists) that many ‘PBF’ projects were started that had significant design and implementation flaws while such design and implementation experimentation had been done previously, and lessons had been learned on the ‘how to’ (the ‘science of delivery’) already. Our credo was therefore: ‘make mistakes, but make original mistakes and do not repeat those that have been made before’. I believe there is a strong demand for the experiential knowledge contained in this toolkit which comprehensively rehashes the experience from key pioneers over the past, say, 15 years.

Three years ago, some authors wrote that the PBF strategy underestimated important constraints to its implementation. Do you agree with this assessment?

First, what is a ‘PBF strategy’? There is no such thing as a “PBF strategy”, there are various PBF approaches, and these approaches evolve continuously. Second: if PBF were easy, it would have been done before. So PBF is not an easy fix, but it is a set of principles that are adapted to each specific context. PBF is unpredictable as a ‘strategy’ in a specific context, as there are so many variables that will influence whether it will succeed or not. The best that one can do as an implementer is to apply as much as possible all elements of PBF approaches that are known to be linked positively with some effect. It is not an exact science, but I guess this is the best advice I can give. The most important constraint is having effective local champions that advocate for the approach. It is a health reform and because it is a reform, we need to appreciate that it has political economy aspects. PBF is not a technical fix, or some sort of vertical program; it is a systemic multi-layered intervention. And this is exactly why we wrote this toolkit: to ‘demystify’ PBF, to describe what worked best and how, and also, what failed.

So far, knowledge on how to implement a PBF scheme has largely been disseminated through the mobility of experts, with a massive involvement of experts from Africa – something remarkable if we compare with previous practices. Still the support from implementing agencies from the North has remained important. Which evolution do you expect in the close future? Any role to be played by the toolkit?  

I expect Southern experts to play even more important roles in the future. Already, the most effective local champions are those who move from their own contexts to other contexts. Quite a few are very effective experts. This toolkit will enable these experts to access knowledge held previously by a few pioneers and to become even better experts. Also, this toolkit is not a final product, but rather a look back in time, up to plus or minus the current period, and say: this is what has been done, this is how it was done, and this is what seemed to work better and this is what was tried and did not work well. In this sense, this toolkit is a benchmark: experts will need to get acquainted with its content, and then move on and build on the knowledge contained in it (and produce a next version). Northern technical assistants will have to adapt to these changing realities: they will have to devise business models that will focus on creating local capacity and be flexible and nimble.  

Some experts, including within the PBF community, are a bit afraid that on some aspects, we move too quickly towards a doctrine. This could create rigidities or too much ‘cut & paste’ of solutions. How does the toolkit deal with this risk?

I am not too afraid of this ‘cut and paste’ labelling. The toolkit was written with a keen eye on this theoretical danger of being labelled as a ‘cookie cutter approach’ and I believe sufficient care has been taken to present a balanced view wherever possible. Nevertheless; this is a TOOLKIT and some degree of advice is necessary and also expected from a toolkit. I will give an example. If for instance you decide to disregard the element of health facility autonomy in your PBF design, do not be surprised if you do not find any effects of PBF in the near future. Even worse, sometimes designs are framed as ‘Rwanda/Burundi type of PBF’ whereas there are major departures from that design. The issue in my opinion is a misunderstanding or lack of knowledge on the contexts where these PBF approaches have evolved so successfully. And this is why this toolkit is so important: the toolkit tells many stories about many different design and implementation elements, which, if pieced together and read as a whole, tell a much more comprehensive story on PBF approaches and especially, on how to make them more effective.

A challenge obviously is that the knowledge on PBF is evolving very quickly. If you had to add a new chapter, let’s say, next year, which new topic would you cover?

Information and Communication Technology (ICT) is an area which evolves rapidly. For instance, the development of tablet based software for the quality checklists with automatic uploads to a web-based platform/dashboard. Also the web-enabled applications through OpenRBF are evolving as we speak, with major work being done in inter-operability with other ICT solutions such as DHIS2. Another area is the increasing interest in moving towards process elements of quality, such as for instance the use of criterion based medical audits or vignettes (case-studies). Furthermore, the issue of urban PBF, where public funds are used to contract private for profit providers through PBF will be a major growth area. Also, the area of equity, of how we target the poor, is evolving really fast. In the World Bank we now work systematically hand in hand with our social protection colleagues, and there is a fair amount of cross-fertilization here.

In the foreword, Tim Evans reminds us that delivering services is important to push the frontier of knowledge forward. Some people think that when the World Bank adopts a new idea, trickle-down effects swiftly follow. So when Jim Kim, the Bank’s President, announces that ‘the science of delivery’ will be a hallmark of his tenure, this raised a lot of expectations among practitioners. Should we interpret this important document as the sign that the World Bank gets serious about implementation issues?

I cannot speak for the World Bank, but I agree that there is a general wave inside the Bank to become much more focused on the poor and to become more effective and efficient in what we do for the poor. This toolkit does just that. If you look at our health portfolio in Africa for instance, you will see that PBF is BIG. And it is set to become even bigger in Africa, while it is slowly taking off in Central and South-East Asia, and trickling into the Arab world and Latin America too.

Do you agree with the view that the experts of the PBF Community of Practice (PBF CoP) should contribute to the next edition? Do you have any plan in this respect?

This is a toolkit written by experts from the PBF – CoP. The way it was done, will enable adding tools to on-line folders in the appropriate chapters which will remain accessible through the links in the e-book, and through the WB website. In the near future I believe that various chapters will need updating and this can be done in various ways. It is my hope that this toolkit, which will be produced in three languages (EN; FR and SP), will be used by our PBF-CoP colleagues who will further enrich and expand it. 


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Un Fonds mondial pour la santé: vers une responsabilité véritablement partagée

3/13/2014

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Isidore Sieleunou

Dans un document de travail récent du Chatham House, Gorik Ooms (IMT) et Rachel Hammonds (IMT) ont exploré si un Fonds mondial pour la santé était une option réaliste à moyen / long terme, à la fois du point de vue des pays «donateurs» et «partenaires ». Isidore Sieleunou a eu un entretien avec le premier auteur. Gorik zoome sur certains des messages clés, les compromis politiques inhérents et les conséquences.

Votre papier est opportun, en ce moment où le débat sur le financement durable de la santé (post-2015) prend de l'ampleur (voir par exemple le thème de la prochaine conférence du PMAC: "Santé Mondiale après 2015: accélérer l’équité"). Pouvez-vous résumer les messages clés du papier?

Un Fonds mondial pour la santé améliorerait considérablement l'efficacité de l'aide internationale pour la santé, en particulier parce que cela accroîtrait la prévisibilité de l'aide sur le long terme, ce qui est essentiel pour l'aide internationale, y compris la planification à long terme.

Il y a des inconvénients pour les pays récipiendaires de l'aide: par son ‘pouvoir de marché’, un Fonds mondial pour la santé serait en mesure d'imposer des conditions que ne peuvent pas imposer une multitude de «donateurs». Mais les avantages l'emportent sur les inconvénients. Comparez-le avec la différence entre la charité et la protection sociale: vous n'avez pas besoin d'être membre de quoi que ce soit pour recevoir la charité, mais vous ne pouvez pas compter sur la charité; pour être inclus dans un régime de protection sociale, vous devez remplir certaines conditions, ce qui peut être gênant.      

Vous soulignez que l'intérêt politique d'un Fonds mondial pour la santé peut provenir d'un coin inattendu - plus particulièrement, vous voyez le problème du réchauffement climatique comme une bonne occasion. Pourriez-vous nous dire pourquoi le changement climatique pourrait aider les pays à se rallier derrière un Fonds mondial pour la santé?

Le changement climatique modifie la nature de la relation entre les pays. Les OMD portent sur la réduction de la pauvreté – ce qui divise le monde en donneurs et receveurs. Les ODD (objectifs du développement durable) sont en lien avec ​​le changement climatique, qui affecte tous les pays et exige des efforts de tous les pays.

En dépit de l'urgence du défi climatique, la priorité pour les pays en développement reste le développement et la réduction de la pauvreté. L’atténuation du changement climatique semble être une idée farfelue pour la plupart des dirigeants africains. Gardant à l'esprit la priorité relativement faible du changement climatique pour les dirigeants africains, qu’est-ce qui vous fait penser que relier un Fond Mondial pour la santé au changement climatique pourrait changer le jeu dans les négociations politiques pour la période post-2015?

Précisément parce que le défi climatique est une priorité plus élevée pour les pays les plus riches, il met les pays pauvres dans une position de négociation plus forte. Ils peuvent dire: "Si vous voulez une responsabilité partagée pour la durabilité de l'environnement, vous devrez accepter la responsabilité partagée de la durabilité sociale. Nos électeurs n’accepteront aucun accord mondial sur le changement climatique pouvant avoir un impact négatif sur notre croissance économique s'il n'y a pas de compensation ".

Pensez-vous qu’il y ait beaucoup de ‘preneurs’ dans les pays du Sud pour un tel mécanisme de solidarité sociale dans le monde, avec les pays qui auront besoin d'argent sur ​​une base permanente, au moins pour quelques décennies? Autrement dit, même si vous estimez que les pays passent de statut de bénéficiaire à celui de donateur (ou même pour les bénéficiaires qui deviennent des «bailleurs de fonds» parce que mettant un petit montant dans le Fond), on aura toujours des pays qui resteront principalement des bailleurs de fonds tandis que d'autres seront essentiellement bénéficiaires. Comment voyez-vous cette idée de l'ajustement de l'aide permanente avec l’idée que maintenant que de plus en plus de pays africains disent qu'ils veulent, à moyen terme, se débarrasser de l'aide au développement, car ils estiment qu'elle est condescendante et les maintient dans une relation de dépendance?

Je peux facilement comprendre la réticence des pays du Sud. Jusqu'à présent, l'aide internationale a été comme un organisme de bienfaisance. Si j’étais en position d'être dépendant de la charité, ma première ambition serait d'être dans une position où je n'aurais plus besoin de la charité.

Mais ma question aux dirigeants des pays du Sud serait: «Comment voulez-vous vous comporter lorsque vous aurez terminé votre dépendance à l'aide? Voulez-vous vous comporter comme les pays les plus riches le font aujourd'hui, et distribuer la charité, ou allez-vous viser quelque chose de mieux, comme la protection sociale mondiale? "Je pense que l'idée de la protection sociale dans le monde s'intègre très bien avec le concept africain de Ubuntu.

Jusqu’ici les chiffres et les estimations ne reflètent que la première étape de la transformation de la charité globale vers la protection sociale au niveau mondial. Je pense que nous devrions passer très rapidement à un régime sous lequel tous les pays contribuent progressivement - la différence entre les deux est illustrée par l'annexe 1 et l'annexe 2.

Dans le contexte géopolitique actuel, comment jugez-vous l'attractivité d’un «Fond mondial pour la santé» pour les pays ‘BRICS’ (Brésil, Russie Inde, Chine et Afrique du Sud)?

Il existe une pression croissante dans les pays ‘BRICS’ pour l’accroissement de la protection sociale - et donc d'augmenter la fiscalité nécessaire pour financer la protection sociale. Ce n'est pas facile, en raison de la concurrence fiscale entre les pays: les pays veulent garder une assez faible imposition pour attirer les investissements. Un fond mondial pour la santé n’organiserait pas seulement des transferts, il fixerait des objectifs pour les niveaux de protection sociale nationaux, et cela permettrait d'atténuer la concurrence fiscale, ce qui est attrayant pour les pays qui souhaitent augmenter le niveau de protection sociale, mais seulement si leurs 'rivaux' économiques en font de même.

En outre, il y a différentes idées pour financer un Fond Mondial pour la santé. Simon Caney - professeur de théorie politique et justice sociale mondiale à Oxford - propose de distribuer les droits mondiaux d'émission par un mécanisme d'enchères. Les pays ou les entreprises qui sont les plus en mesure de «transformer» les émissions de gaz à effet de serre en avantages économiques seraient prêts à payer le prix fort. Le procédé pourrait financer un fond « environnement vert et social », y compris un fonds mondial pour la santé. Ce pourrait être beaucoup plus attrayant pour les pays BRICS que les plafonds d'émission par pays qui sont actuellement sur ​​la table de négociation.

Un certain nombre de bailleurs de fonds et acteurs internationaux soutiennent que l'idée d'un Fond mondial pour la santé reste une approche plutôt monopolistique. La compétition des idées, des mécanismes de financement et des produits, conduisent souvent à de meilleurs résultats, disent-ils. Que répondriez-vous à eux? Pensez-vous qu’un Fond Mondial pour la santé pourrait affecter la qualité de l’aide au développement en santé dans un sens négatif en raison du manque de concurrence? Ou est-ce l'inverse?

Encore une fois, comparons la avec la différence entre la charité et la protection sociale. Sous la charité, tous les gens riches donnent autant qu'ils veulent, quand ils veulent, à qui ils veulent. Certaines personnes riches peuvent être généreux, et peuvent devenir moins généreux si on leur demandait ou contraignait de payer plus d'impôts pour financer la protection sociale. La «concurrence» entre Bill Gates, Warren Buffett et d'autres personnes riches peut avoir certains avantages qui risquent de disparaître. La protection sociale nécessite une coordination: une entité centrale qui perçoit les cotisations et décide comment redistribuer. Il semble probable que certains pays ou certains problèmes de santé particuliers subiraient des conséquences négatives, mais dans l'ensemble, je préférerais toujours être un membre d'un régime de protection sociale, que d'être le bénéficiaire de la charité.

Vous avez travaillé sur la responsabilité sociale collective, y compris cette idée d'un Fond Mondial pour la santé, pour une partie importante de votre carrière. Etes-vous optimiste quant aux perspectives de la solidarité dans le monde entier, ou la pérennité sociale comme vous l'appelez?

Oui, cela se produira. Mais je ne sais pas quand. Je suis devenu assez pessimiste sur le calendrier, mais je reste confiant que cela se produira. L'alternative d'un régime mondial de protection sociale augmente l'isolationnisme - chaque pays tentant de faire face à ses propres problèmes à sa façon. Il n'ya pas d'avenir pour l'isolationnisme. Ulrich Beck peut paraître naïf quand il soutient que le changement climatique pourrait sauver le monde, mais il marque un point. Les changements climatiques nous obligent à penser au-delà de l'Etat-nation.

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Africa Health Forum: Investing, with the Private Sector, in Health in Africa

3/9/2014

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In this blog post, Serge Mayaka (Kinshasa School of Public Health and PhD student at the Université Catholique de Louvain) interviews Mrs Agnes Soucat, Director of the Human Development Department at the African Development Bank regarding an event that AfDB will jointly organize with the Jeune Afrique Group, in Geneva on 16 and 17 May 2014 (prior to the World Health Assembly). The Forum is designed as a platform bringing together key policy makers and heads of laboratories, financial institutions and all industries in the health sector.

What is the analysis underlying the organization of this conference?

Africa is undergoing profound changes, all of which have an impact on human capital development and on how various stakeholders from the public and private sectors consider investment in the health sector. Demography in Africa is characterized by a young and fast-growing population; this offers very dynamic growth prospects, provided there is judicious investment in human capital and a full leveraging of skills. Economically, African countries have been experiencing a growth rate of 5% on average for the past decade and continue to resist global crises. The private sector is more than ever present. On the technology side, the continent is experiencing the technological curve, with spectacular advances in information and communication technology. By 2025, mobile telephony network coverage will be almost universal. Politically, democracy is gaining ground in Africa, and governance standards continue to improve, thanks to the growing demand for citizen participation and accountability, which has encouraged democratic reforms and reduced conflict and civil wars. 

Aware of these changes, we believe that traditional investment in health is not an appropriate response. The challenges are different. The actors have changed. The technological means available have also changed. Healthcare supply and demand has evolved. Based on these facts, we conceived the Africa Health Forum as the first public-private forum on health economics in Africa. The Forum will acknowledge recent developments on the continent and give to the private sector a place equivalent to that of the public sector and foster interaction between the two. The Forum will highlight four main themes, in tune with the major changes the continent is undergoing, to guide investment in health: employment, governance, new technology and financing. 


Could you kindly illustrate what this new health investment model would mean, for instance, for an organization such as AfDB?

I think the multisector approach is a better option, because the continent's challenges go beyond the traditional health investment framework. In addition, the private and public sectors need to better develop their synergies for more efficient investments in the health sector. As part of its new human development strategy, AfDB will support investment in health through three thrusts: 

  1. Development of skills and technology to improve competitiveness and employment prospects. For instance, AfDB will support the development of the pharmaceutical sector on the continent, public-private partnerships and skills development to ensure the provision of quality care; 
  2. Promotion of efficiency and inclusion in healthcare service delivery. The objective is to optimize the use of financial resources and strengthen accountability and citizen participation in governance, provide equitable and better quality services attuned to the citizens' choices and contribute to the stability of societies characterized by openness; and 
  3. Establishment of inclusion-enhancing financial and social systems. 

 Based on your experience on the current dynamics in Africa, what do you see as the promising innovative solutions to enhance the development of the health sector in Africa?

African States and all public and private actors must mobilize to carry on the progress achieved but a new paradigm shift is needed to promote the development of the health sector. African states should mobilize more domestic resources to invest in health, and the current environment is favourable. The continent is indeed experiencing a remarkable growth rate making it possible to invest more national resources while putting in place policies that enhance equity and social justice. The fiscal space prospects linked with the exploitation of natural resources are also promising. It is also noteworthy that States which have made progress in terms of good governance, accountability and transparency in the use of resources for health are those with the best results in mortality reduction. African States should also intensify efforts to optimize the use of resources invested in health in sync with the Tunis Declaration of July 2012 on Value for Money, Sustainability and Accountability in the Health Sector.  They must create stronger incentives for evidence-based resource allocation and for activities with a high impact on health.

How is this different from what was already attempted in the past?

In the past, African countries relied heavily on foreign aid to finance health; balance of power must now be readjusted through the use of innovative financing mechanisms. Aid is on the decline due to the global financial crisis and donors' new priorities. The resulting financing gap must be bridged at the national level and States must use innovative ways to raise additional funds. For instance, several African countries are analysing sustainable financing options for HIV and malaria, and their implementation mechanisms. This includes in particular (Malaria Bonds), deductions from banking and airline ticket transactions, taxes on alcohol or cigarettes. Partnerships with the private sector are obviously also essential. 

Precisely: in terms of health financing, what according to you is the role of the industrial and commercial private sector in Africa?

The private sector is a key element in meeting the challenges currently facing the health sector in Africa. The private sector plays an important role in Africa at all levels of health service delivery and its increased engagement could help to improve the quality and accessibility of services, accountability, create jobs and promote robust economic growth on the continent. The private sector has a key role to play to trump the ongoing technological revolution which offers new options for health service management, financing and delivery.

In this case, a new vision for the health sector would be necessary... 

Indeed, the health sector is a productive sector that can provide about 1.5 million jobs for African youths by 2020 and contribute to the economic growth of the continent. For example, the development of the pharmaceutical industry and an increase in the demand for medicines create opportunities for research and development, manufacturing, sale and distribution of drugs. Outside the commercial sphere, there are several opportunities as well for the development of social entrepreneurship in the sector.

Can you give us more information on the format of the Africa Health Forum? How will the momentum be maintained after Geneva?

The Africa Health Forum is intended for policy makers in Africa, both from the public and private sectors. It aims to provide African policy-makers with the information and tools they need to make informed decisions that will help them better invest in the health sector, throughout their country or region.

Therefore, the Forum is designed as a networking platform. 'B2B' (Business to Business) meetings will enable the participants to meet confidentially in dedicated lounges. An exhibition space will also be made available to companies wishing to present their activities to participants. Hence, the Forum will make it possible to engage in discussions that could culminate in partnerships.

In addition, AfDB, as is already the case, will continue its regular dialogue with governments driving through ideas, best practices and solutions presented at the Forum.  AfDB will also listen to the public and private sector representatives to explore opportunities for collaboration and support for their initiatives. Lastly, the Africa Health Forum is designed as a regular come-together; the second edition of the Forum will provide an update on progress achieved and maintain contact with the participants of the first edition. 

For more information, please visit the forum website. 

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A Global Fund for Health: towards truly shared responsibility

3/4/2014

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Isidore Sieleunou

In a recent Chatham House working group paper, Gorik Ooms (ITM) & Rachel Hammonds (ITM) explored whether a Global Fund for Health is a realistic option in the medium/long term, both from the perspective of so called “donor” and “partner” countries. Isidore Sieleunou had an interview with the first author. Gorik zooms in on some of the key messages, political trade-offs involved and implications.


Your paper comes timely, now that the ongoing (post-2015) debate on Sustainable Financing for Health is gaining momentum (See for example the theme of the next PMAC conference: “Global Health Post 2015: accelerating equity”). Could you summarize the paper’s key messages?

A Global Fund for Health would greatly improve the efficacy of international assistance for health, in particular because it would increase the predictability of assistance in the long run, which is essential for including international assistance in long term planning.

There are disadvantages for the countries receiving the assistance: a Global Fund for Health would be able to impose conditions in a way that a multitude of ‘donors’ cannot. But the advantages would outweigh the disadvantages. Compare it with the difference between charity and social protection: you don’t need to be a member of anything to receive charity, but you cannot rely on charity; to be included in a social protection scheme, you need to fulfill certain requirements, which can be inconvenient.        

You stress that the political interest for a Global Fund for Health may come from an unexpected corner -  more in particular, you see the issue of global warming as a good opportunity. Could you tell us why climate change could help countries rally behind a Global Fund for Health?

Climate change changes the nature of the relationship between countries. MDGs are about poverty reduction – that divides the world into donors and recipients. SDGs are about climate change, that affects all countries and requires efforts from all countries.  

In spite of the urgency of the climate challenge, the priority for developing countries is still development and poverty reduction. Especially climate change mitigation seems to be a far-fetched idea for most African leaders. Keeping in mind the relatively low priority of climate change for African leaders, what makes you think linking a Global Health fund with climate change could be a game changer in the political negotiations for the post-2015 era?

Precisely because the climate challenge is a higher priority for the wealthier countries, it puts poorer countries in a stronger bargaining position. They can say: “If you want shared responsibility for environmental sustainability, you will have to accept shared responsibility for social sustainability. Our constituencies will not accept any global deal on climate change that may have a negative impact on our economic growth if there is no compensation.”   

Do you think there are many takers in the Global South for such a worldwide social solidarity mechanism, with countries who will require money on a permanent basis, at least for some decades? Put differently, even if you allow for countries moving from recipient to donor status (or even for recipients putting a small amount of money in the Fund so that they are also ‘donors’), still countries will mainly be donors whereas others will mainly be recipients. How do you see this idea of permanent assistance fit with the ‘Africa rising’-narrative, now that more and more African countries say they want to get rid of development aid in the medium term, as they feel it’s patronizing and keeps them in a relationship of dependency?

I can easily understand the reluctance in the Global South. So far, international assistance has been like charity. If I were in the position of being reliant on charity, my first ambition would be to be in a position where I no longer need charity.

But my question to the leaders of the Global South would be: “How do you want to behave after you will have ended your reliance on aid? Will you behave as the wealthier countries do today, and hand out charity, or will you aim for something better, like global social protection?” I think the idea of global social protection fits very well with the African concept of Ubuntu.

The figures and estimates so far only reflect the first step of the transformation of global charity to global social protection. I think we should move very quickly to a regime under which all countries contribute progressively – the difference between both is illustrated by annex 1 and annex 2.    

In the current geopolitical environment, how attractive is a ‘Global Fund for Health’ for BRICS countries?

There is growing pressure in BRICS countries to increase social protection – and therefore to increase taxation needed to finance social protection. This is not easy, because of tax competition between countries: countries want to keep taxation low enough to attract investment. A global fund for health would not only organise transfers, it would set targets for domestic social protection levels, and that would mitigate tax competition, which is attractive for countries that would like to increase social protection levels but only if their economic ‘rivals’ do the same.

Furthermore, there are different ideas to finance a Global Fund for health. Simon Caney – professor at Oxford in Political Theory and Global Social Justice – proposes to distribute global emission rights through an auction mechanism. The countries or companies that are most able to ‘transform’ emission of greenhouse gasses into economic benefits would be willing to pay the highest price. The proceeds could finance a ‘green and social environment’ fund, including a global fund for health. This could be a lot more attractive for BRICS countries than the emission ceilings per country that are on the negotiation table now.

A number of donors and international stakeholders say the idea of a Global Fund for health remains a rather monopolistic approach. Competition of ideas, financing mechanisms and products often leads to better results, they say. What would you answer to them? Do you think a Global Fund for health might affect the quality of DAH in a negative way due to lack of competition ? Or is it the other way around?

Again, compare it with the difference between charity and social protection. Under charity, all rich people give as much as they want, when they want to, to whom they want to give. Some rich people can be generous, and may become less generous if they were asked or forced to pay more taxes to finance social protection. The ‘competition’ between Bill Gates, Warren Buffett and other wealthy people may have some advantages that may disappear. Social protection requires coordination: a central body that collects contributions and decides how to redistribute. It seems likely that some particular countries or some particular health issues would experience negative consequences, but overall, I would always prefer to be a member of a social protection scheme, over being the beneficiary of charity.         

You have been working on collective social responsibility, including this idea of a Global Fund for health, for a substantial part of your career. Are you optimistic about the prospects of worldwide solidarity, or social sustainability as you call it?

Yes. It will happen. But I don’t know when. I’ve become fairly pessimistic about the timing, but remain confident that it will happen. The alternative for a global social protection regime is increasing isolationism – every country trying to deal with its own problems on its own. There is no future for isolationism.  Ulrich Beck may sound naïve when he argues that climate change might save the world, but he has a point. Climate changes forces us to think beyond the nation state.     

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