Private support of public health

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Abstract

Although private funding of health initiatives has existed for some time, in recent years, private investment in health, particularly in developing countries, has increased considerably and has often resulted in improvements in health and alleviation of suffering. However, the donation of large sums of money to address one or a handful of health problems can have, and has occasionally had, unintended repercussions in developing nations. Left unchecked, cause-specific funding may undermine the public health systems of these countries, rather than improving them. The purpose of this chapter is to present the positive and negative aspects of private funding of public health and to make suggestions to minimize the harmful unintended negative impacts and to maximize positive outcomes of donor investments in public health.

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History

The late twentieth and early twenty-first centuries have witnessed a huge influx of private support for public health as exemplified by generous gifts from the Bill and Melinda Gates Foundations, Warren Buffett, the William Clinton Foundation, the Carter Center, the Wellcome Trust, industry, professional and non-governmental organizations, and others. However, such generous giving, especially by Americans, actually dates back to the formation of the original foundations in the earliest years of the twentieth century. The earliest foundation in the United States was the Russell Sage Foundation founded in 1906, which had a limited focus on working women and social ills. The establishment of the large, broadly focused foundations began with the founding of the Carnegie Foundation by Andrew Carnegie in 1911 ‘to do real and permanent good in this world’ (Carnegie Foundation 2007) followed by the founding of the Rockefeller Foundation in 1913 (Rockefeller Foundation 2007).

These early gifts had a significant impact on public health. The Rockefeller Foundation, for example, founded the International Health Commission in its first year. This was the first appropriation of funds by private sources for international public health activities and has helped 52 countries on 6 continents and 29 islands to improve their public health systems. In the same year, the Foundation began 20 years of support for the Bureau of Social Hygiene which focused on research and education on birth control, maternal health and sex education. Moreover, they played a key role in founding the world’s first schools of public health, first at Johns Hopkins, then at Harvard and later in other parts of the United States, as well as in 21 foreign countries. Overseas, they helped to establish the London School of Tropical Medicine and Hygiene with a large gift in 1921, as well as the China Medical Board (1914) and the Peking Union Medical College (1921), both of the latter having played a significant role in the development of public health in China.

Since the establishment of these early foundations, the culture of donation to support public health has increased, particularly in recent years. Now, there are over 40 major foundations based in both the United States and abroad (see Table 12.13.1), as well as countless smaller ones. This increase can be attributed in part to at least two phenomena: The AIDS epidemic and the rise in public pressure for corporate social responsibility.

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AIDS and the new culture of donation

With the discovery of therapy that could control the progression of HIV disease came the recognition, strongly expressed at the International AIDS Meeting in 1996, that millions of people, especially in developing countries, were being denied access to treatment because of the cost of the drugs. This realization spurred a tripling of funding for international projects to provide treatment for HIV/AIDS and to address the problems of malaria and tuberculosis, two of the major diseases responsible for loss of life and disability internationally. The increased funding was led by the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM 2007) and the Bill and Melinda Gates Foundation (Bill and Melinda Gates Foundation 2007) which by 2006 had total assets of US$33.7 billion, more than the total budget of many developing countries. Every year, the Gates Foundation gives away approximately US$800 million approaching the total budget of the World Health Organization and equivalent to the budget for fighting infectious diseases given by the US Agency for International Development. The commitment of the Gates Foundation stimulated additional large donations by Warren Buffett and the William Clinton Foundation.

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Corporate social responsibility (CSR) and public–private partnerships

Concurrent with these increases in funding for health has been the rise of CSR. Although corporations are required to abide by certain laws and regulations to reduce any adverse consequences of their businesses, CSR takes this concept further to encourage corporations to take actions to improve the quality of life of their employees and their families, customers, stakeholders, and the community in general (WBCSD 2000). As part of the Millennium Development Goals (UN 2008), corporations, especially large multinationals, are encouraged to increase their awareness of their impact on the societies in which they operate. Many corporations have since established a CSR division to run social programmes. For example, the Standard Chartered Bank, recognizing the need to maintain a stable and healthy workforce, has an extensive HIV/AIDS programme to provide healthcare and support for staff and their families affected by HIV/AIDS in Africa (Standard Chartered 2006). General CSR programmes may include production of healthful foods, design and manufacturing of low-emission vehicles with higher standards of safety, improvement of the work environment of workers, control of industrial waste, etc.

In addition, corporations, particularly pharmaceutical companies, have been increasingly signing public–private partnerships. These are generally joint ventures between private industry, government, or international agencies such as the WHO or UN agencies, and civil society including universities or NGOs to achieve a shared health objective (Widdus 2005). There were more than 90 international partnerships in health in 2004 (Nishtar 2004). The majority address infectious diseases, notably AIDS, TB, and malaria. Some involve individual governments or NGOs or both forming an alliance with the for-profit sector. For example, Sanofi-Aventis has an extensive international programme of humanitarian sponsorship, including a partnership with the Nelson Mandela Foundation and the South African Department of Health to provide free tuberculosis treatment in areas badly affected within South Africa (Sanofi-Aventis 2008). Other partnerships may involve many players. The most notable are the global health alliances, such as the Global Alliance for Vaccines and Immunizations, Roll Back Malaria, the Stop TB partnership, the Global Polio Eradication Program, and the International AIDS Vaccine Alliance. They may be principally driven by a company, be legally independent, or hosted by a civil society organization (Nishtar 2004). Stop TB, for example, comprises a network of more than 500 partners, including governments of both developed and developing countries, research and technical health institutes, multilateral organizations, civil society, pharmaceutical companies and other industry partners and is housed within the WHO (Stop TB 2007).

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Examples of private support

Private support of public health, given by foundations, industry, pharmaceutical companies, and professional organizations has been directed towards disease control and treatment, poverty alleviation, education, training of health workers, infrastructure development, research, improved agricultural practices, health information dissemination, and sponsorship of the many global health alliances.

Specific examples include the provision of drugs and the reduction of drug prices for developing countries, the earliest example being the Metzican Donation Program by Merck & Co. Inc. for treatment for onchocerciasis (river blindness) in West Africa in 1988 (Mectizan 2008). In 1998, GlaxoSmithKline provided albendazole for treatment of lymphatic filiarisis as part of the Mectizan programme. To date, this ongoing programme has reached more than 40 million people (Mectizan 2008).

Another major contribution has been the establishment of special training programmes and scholarships/fellowships for training health personnel. Many foundations are set up for this purpose alone or as part of a broader portfolio. For example, the Robert Wood Johnson Foundation has a clinical scholars programme for US students (Robert Wood Johnson Foundation 2008). Additionally, foundations may provide gifts to schools, such as equipment or teaching resources.

Another important contribution of private agencies has been to research. The Hughes Medical Institute, for example, was established by Hughes Aviation to conduct research into human illness (HHMI 2008) (although the motivation for doing so has been attributed to tax evasion rather than philanthropy; Wikipedia 2008). The Gates Foundation currently supports a large number of research projects related to HIV prevention strategies including vaccine and microbicide development. There are also the very significant contributions made by pharmaceutical companies to the research and development of vaccines and treatments, both independently and in public–private partnerships. Increasingly, these efforts are focusing on the so-called ‘neglected diseases’ that disproportionately affect the world’s poorest nations.

Industry is realizing that improving the health of the public is in their best interest in the long run. These generous gifts and actions have unquestionably had a very significant impact on the growth of public health in the twentieth century and played a significant role in shaping the character and missions of public health. For these significant contributions to ‘promote the well-being of mankind throughout the world’, they are to be commended (Rockefeller Foundation Charter 1913).

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Unforeseen problems

Many of these very generous gifts have benefited the recipient countries enormously and have achieved goals which otherwise would have been impossible to achieve. There is no question that the recent surge in international giving, which shows no signs of slowing, is a positive step towards reducing the disparities between the rich and poor countries and benefiting all mankind. Why, then, have there been critics of this surge in generosity?

From the beginning, the foundations have determined their goals for giving based on the personal perspectives of their founders and subsequent leaders. Often, they did not consult public health leaders in determining these goals. This strategy has the risk of distorting the public health agenda with the influx of large sums of money, which often dwarfs the national budgets of the recipient countries and cannot be matched by the local government. This presents a myriad of problems for these countries.

First, their public health agenda is being determined by outside agencies. This agenda may not coincide with the country’s needs, and may deplete existing resources, especially trained personnel. When a huge donor driven programme is established, it must rapidly acquire an infrastructure for its management. Programmes will often attract qualified personnel by providing higher salaries than can realistically be provided by local government agencies. Thus, much of the staff is drawn from the existing public health infrastructure, leaving fewer staff within government to work on other health priorities. The result—the goals of the donors are met, but at the expense of the country’s health system resulting in deterioration of other important public health programmes and exacerbating the existing public health human resource crisis extant in most developing countries. For example, in Haiti, the dramatically improved HIV/AIDS situation has paralleled a decline in other measures of the population’s health, including infant mortality (Farmer & Garrett 2006).

Second, the governments, in many developing countries, have invested little of their funds, often less than 5 per cent, in health. Large infusions of donor funds allow these countries to continue to underfund health. Kwame Ampomah, a Ghanaian with the UNAIDS programme in Gaborone, Botswana, asserts that ‘you need a clear health system with equity that is not donor-driven’ (Garrett 2007).

The influx of huge sum of money can also contribute to corruption, inflation, and destabilization of the economy. In countries with entrenched bureaucracies and rampant corruption, the donor funds may not all be used for implementation of public health programmes. In the absence of any evaluation to measure the benefits of a programme or any auditing to account for spending, donations may simply serve to exacerbate corruption and bureaucracy. In addition, increasing the salaries of some, especially government officials, can widen the rich–poor gap and generate inflation (Garrett 2007).

Further, programmes that appear acceptable to the Western intellect may not be culturally acceptable to people of other countries. For example, family-planning programmes, in order to be successful, had to demonstrate that smaller families meant increased survival for the children and an increased probability that parents would have a viable male to support them in their old age.

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Sustainability

The donation of large sums of money to tackle specific health problems does not lend itself to a sustainable solution. For example, the Gates Foundation now provides 17 per cent of the global budget (US$86 million) to eradicate poliomyelitis and also supports vaccine programmes for HIV/AIDS, Japanese encephalitis, and other diseases, as well as research in HIV/AIDS, particularly towards development of female-controlled interventions. In an effort to assist women to become more independent, the foundation has given money to the Grameen Foundation, whose founder recently received the Nobel Peace Prize. With the Rockefeller Foundation, the Gates Foundation has also provided funds to support improved agricultural practices in developing countries. But, when Gates’ and other donor monies are discontinued, are these programmes going to be sustained by the local governments which do not have the resources of these large donors?

Currently, massive funding is being injected to provide treatment for HIV/AIDS to those in need, but it is likely that other major health problems will occur in the future which will divert donors’ attention away from HIV/AIDS. The countries now receiving these massive infusions of money for treatment programmes for HIV/AIDS patients will not be able to sustain them. Thus, it is unclear what the long-term impact of the huge influx of funds will be on HIV/AIDS. A larger investment in prevention may have a more long-lasting benefit, but currently the majority of donors have concentrated their funds on treatment with little allocated to prevention, in part because it is difficult to show immediate outcomes with prevention.

The implementation of demonstration/pilot projects needs to consider whether the projects can be sustained by the local government if they are demonstrated to be effective, and whether it will be feasible to upscale the project to the point where it will have a significant impact on the health of the country. Often, outside support to maintain a programme is provided without seeking in-country solutions to supply issues, and there is a focus on treatment rather than prevention. In the case of pharmaceuticals, for example, the solution is usually to help countries find cheap avenues for importing drugs, rather than helping them to establish their own pharmaceutical plants to manufacture generic medicines. By supporting development of local industries, donor money can have an impact that reaches far beyond health.

Reliance on imported pharmaceuticals has very real risks for disease control. Cessation of an externally funded programme, including the drug supply, can lead to the resurgence of disease, as was the case in Uganda when sleeping sickness quickly resurfaced once control had apparently been achieved and the project staff withdrew (Widdus 2005). Irregular supply or inadequate storage facilities, both common in developing countries, can lead to treatment failure and subsequent resistance to medications. Simple mismanagement of programmes has also had serious adverse consequences—such as the reckless provision of TB therapy without adequate medical supervision in KwaZulu Natal, which has led to the evolution of the most drug-resistant strains of the mycobacteria (Garrett 2007). Ironically, by providing quick fixes to a problem, some foundations are doing what medicine has long known as unsustainable—treating symptoms without preventing the cause!

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Coordination

In some countries, there are so many donors, each targeting their own agendas, that the country’s public health professionals are not aware of all the programmes being conducted in their country. Without this information for coordination, national programmes may be duplicating donor programmes while other urgent needs may be unmet. This lack of coordination is exacerbated in countries where the donors feel that the government is corrupt and therefore bypass it. In developed countries, governments that have played a central role in funding health have had better control over growth and may lead to a more efficient health service (Navarro 1985). Thus, external investment in a country’s health should prioritize partnering with, improving and supporting existing public infrastructures, and should recognize that a country’s elected government may be able to judge its health priorities better than an external organization based in a rich country (Widdus 2003). Donors may also bypass established health authorities who work closely with governments to determine priorities, such as the WHO, which undermines their role in international health and fractures the system further.

For HIV/AIDS, at least, UN agencies have overseen the development of the ‘Three Ones’ agreement: One agreed-upon HIV/AIDS action framework that provides the basis for coordinating the work of all partners; one national AIDS coordinating authority, with a broad based multi-sector mandate; and one consensus for country-level monitoring and evaluation system (WHO 2004). Similar agreements are needed for donor-supported health projects in general. China provides a unique example of how government authoritarianism has helped achieve this kind of coordination. Although it was motivated by a different purpose, China insists that large donor agencies have government approval before being allowed to work in-country, and thus, the relevant officials have been able to have a direct role in deciding where and how donor money should be channelled.

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Dubious motives

Because of charitable tax deductions by the US government, the foundations are able to reduce their tax burden by as much as 25 per cent. The New York Times has estimated that charitable deductions cost the US government US$40 billion in lost tax revenue in 2006 (Strom 2007). Thus, to some extent, the foundations, not the US government, are determining where public health funds are spent. Recognizing this fact, Eli Broad, one of the major donors, has said that, ‘What smart entrepreneurial philanthropists and their foundations do is get greater value for how they invest their money than if the government were doing it’ (The New York Times, September 6, 2007). Not everyone would agree with him. Foundations often determine their targets and objectives on emotional grounds rather than an objective assessment of international and national need.

It is well to remember that the founders of many of these large foundations or organizations obtained their massive wealth though questionable business and labour practices—exploitation of the very public that these foundations strive to serve! Thus, it is not surprising that the motives of these organizations are viewed with suspicion (Reich 2000). Several of the large foundations have been criticized because they obtained their funds through questionable business practices and currently derive some of their income from investments that negatively impact the public and the environment (Los Angeles Times, January 7, 2007, January 8, 2007). Thus, they help the public with one hand while harming it with the other.

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Recommendations

Clearly, the generous giving of the foundations, industry, and private donors has benefited public health greatly. Nonetheless, they have sometimes also had unintended negative consequences. How can the behaviour of the foundations and other donors be modified to maximize the positive impact and minimize the negative? Several changes, suggested below, may contribute to this goal:

• ♦ Careful objective assessment of the goals of the foundation vis-a-vis the needs of the proposed recipient countries

• ♦ Consultation with health leaders of the recipient countries and the World Health Organization on the health priorities/needs of the recipient countries

• ♦ Consideration of the impact that the infusion of money and the programme will have on the existing public health structure and economy of the country

• ♦ Strengthening the existing national and local public health infrastructures by incorporating foundation programmes into the existing public health system

• ♦ Periodic evaluation of the impact of the donor’s programmes by an objective group not affiliated with the donors, but including local expertise

• ♦ Establishment of advisory committees that include both international and local public health experts from developing countries and targeted areas

• ♦ Introducing ethical evaluations, as many universities currently do, in determining in which companies, institutions and commodities to invest, so that investment practices are not counter to the charitable goals of the donor/foundation. Investments in companies, etc. that negatively impact the health and quality of life of the public to make money to do good do not make sense

• ♦ Implementation of projects that can be sustained by the local governments when funding is discontinued

• ♦ Partnering with countries to contribute to the programmes in an effort to encourage countries to increase their investment in health

• ♦ Investment in local businesses to reduce reliance on external sources of health consumables

• ♦ Development of clear governance mechanisms, as well as transparent policies and procedural frameworks that facilitate monitoring and evaluation

Many of these recommendations have already been incorporated by the Global Fund to Fight AIDS, Tuberculosis and Malaria and other private donors. Private funding of public health has contributed greatly to the goals of public health. Let us hope that foundations, industry, and other private donors/agencies will continue to generously support public health in ways that will strengthen the public health structures, stability, and well-being of the recipient countries.