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Alexandra Kaasch
University of Sheffield, UK
Bielefeld University, Germany
HYPERLINK "mailto:sop04amk@sheffield.ac.uk" sop04amk@sheffield.ac.uk
Overlapping and competing agencies
in
global health governance
WHO, World Bank, and OECD in the guidance of
national health care systems
Paper prepared for the ISA RC19 Annual Academic Conference
Florence, 6-8 September 2007
Abstract:
In their attempts to provide for functioning health care systems, national policy-makers increasingly refer to international governmental organisations (IGOs) as sources of advice, information, and data. This is paralleled by a number of IGOs having identified health care systems as part of their work. Current global health governance is characterised by a high number of overlapping and competing institutions, instead of any effective system with particular organisations in charge of defined health policy fields. Based on Deacons ADDIN EN.CITE Deacon199736e.g. 366Deacon, BobHulse, MichelleStubbs, PaulGlobal Social Policy: International Organizations and the Future of WelfareGlobal Social Policyglobal social policysocial policyinternational organizationwelfare stateinfluence1997LondonSAGE(e.g. Deacon et al., 1997) approach to studying global social policy and governance, this paper asks: What are the implications of the engagement of three IGOs (WHO, World Bank, OECD) in the same dimension of global social policy (the guidance of national health care systems) for global health governance?
The analysis is based on (1) the organisations constitutions, as well as documents explaining and justifying their engagement in global health policy (e.g. websites, strategy papers); and (2) the respective organisations reports, policy papers, and similar documents on health care systems; and (3) on interviews with staff of the three IGOs. The IGOs are compared regarding (1) their mandate or legitimacy for engaging in the guidance of national health care systems; (2) the content of their policy advice; and (3) their means of disseminating their respective ideas.
The paper shows that while having different mandates, all engage in the guidance of national health care systems. Their respective ideas on health care systems differ only slightly. And to quite some extent they also diffuse their ideas in the same manner. Concluding, the global discourse on health care systems is much less characterised by controversy on different policy models than that on pensions. There is a considerable overlap in the organisations activities, however they rather compete for credibility and trustworthiness.
Overlapping and competing agencies in global health governance
WHO, World Bank, and OECD in the guidance
of national health care systems
Alexandra Kaasch
Introduction
The structure and reform of health care systems is currently an issue in various countries all over the world. At the same time, global health debates and activities are significantly characterised by an emphasis on the importance of health care systems when tackling more specific health problems such as the fight of particular diseases. From the G8 meetings to the World Health Organisation (WHO) to the Global Fund to Fight AIDS, Tuberculosis and Malaria, and many others, all call for more strengthening of national health care systems in order to make other, more specific interventions and programmes work in a sustainable way. While national policy-makers increasingly refer to international governmental organisations (IGOs) as sources of advice, information, and data on health care systems; several IGOs have identified health care systems as important part of their work. But how is national health care system development being supported or guided by supranational organisations?
Traditionally, health policy has first and foremost been understood and studied as essentially a national matter. In addition, there are a number of comparative studies ADDIN EN.CITE Moran1999327e.g. 3276Moran, MichaelGoverning the Health Care State. A Comparative Study of the United Kingdom, the United States and Germanyhealth carecomparative perspectiveGreat Britain/UKUSAGermany1999ManchesterManchester University PressBlank20047417416Blank, RobertBurau, ViolaComparative Health Policy2004BasingstokePalgrave MacmillanRothgang200587687617Rothgang, HeinzCacace, MirellaGrimmeisen, SimoneWendt, ClausThe changing role of the state in healthcare systemsEuropean Review187-21213Supp. No. 12005Freeman20003253256Freeman, RichardThe Politics of Health in Europequalitative researchhealth careEurope2000ManchesterManchester University PressBambra200568168117Bambra, ClareWorlds of welfare and the health care discrepancySocial Policy and SocietySocial Policy and Society412005(e.g. Moran, 1999, Blank and Burau, 2004, Rothgang et al., 2005, Freeman, 2000, Bambra, 2005b), analysing the nature of health care systems (e.g. their functions), and developing typologies of health care systems (focusing mainly on OECD countries). It has, however, also been shown that various supra-national actors play a part in shaping national health policy ADDIN EN.CITE Koivusalo199737e.g. 376Koivusalo, MeriOllila, EevaMaking a Healthy WorldHealthy Worldhealth careinternational organizationinfluence1997HelsinkiSTAKESLee200220120128Lee, KelleyBuse, KentFustukian, SuzanneHealth Policy in a Globalising Worldhealth carehealth policyglobalisation2002CambridgeCambridge University PressHein200389089028Hein, WolfgangKohlmorgen, LarsGlobalisation, Global Health Governance and National Health Politics in Developing Countries. An Exploration Into the Dynamics of InterfacesSchriften des Deutschen bersee-Instituts Hamburg602003HamburgDeutsches bersee Institut(e.g. Koivusalo and Ollila, 1997, Lee et al., 2002, Hein and Kohlmorgen, 2003). This includes detrimental effects of economic globalisation and trade liberalisation on populations health and health policy ADDIN EN.CITE Koivusalo1999728e.g. 7286Koivusalo, MeriWorld Trade Organization and Trade-creep in Health and Social PoliciesWTOhealth caresocial policy1999HelsinkiStakesKoivusalo200391291217Koivusalo, MeriThe Impact of WTO Agreements on Health and Development PoliciesGASPP Policy BriefGASPP Policy Brief3Jan 20032003(e.g. Koivusalo, 1999, Koivusalo, 2003); similar reform needs in many countries leading to mutual policy learning and diffusion ADDIN EN.CITE Braun2004356e.g. 35627Braun, DietmarGilardi, FabrizioDiffusion Without Convergence: Theory, Methods and an Application to Health Care Reformsdiffusionconvergencehealth carehealth care reform200423-24 April 2004HamburgUniversity of HamburgPaper presented at the workshop "Sources of Cross-National Policy Convergence"Inoue200690190117Inoue, KeikoDrori, Gili S.The Global Institutionalization of Health as a Social Concern. Organizational and Discursive TrendsInternational SociologyInternational Sociology199-2192122006March 2006(e.g. Braun and Gilardi, 2004, Inoue and Drori, 2006); or health causes and effects crossing borders. At the same time, there are also forms of guidance of national health policy through supranational actors ADDIN EN.CITE Deacon20078178176Deacon, BobGlobal Social Policy and Governance2007LondonSageDeacon199736366Deacon, BobHulse, MichelleStubbs, PaulGlobal Social Policy: International Organizations and the Future of WelfareGlobal Social Policyglobal social policysocial policyinternational organizationwelfare stateinfluence1997LondonSAGE(Deacon, 2007, Deacon et al., 1997), in the sense of IGOs and other actors producing knowledge and giving advice to national policy-makers concerning the organisation and the reform of health care systems.
Who is providing for such a guidance? Global health governance in general is characterised by a high number of different actors ADDIN EN.CITE Lee2002389e.g. 3895Lee, KelleyGoodman, HilaryLee, KelleyBuse, KentFustukian, SuzanneGlobal policy networks: the propagation of health care financing reform since the 1980sHealth Policy in a Globalising World97-119health careglobalisationhealth care financing2002CambridgeCambridge University PressKoivusalo199737376Koivusalo, MeriOllila, EevaMaking a Healthy WorldHealthy Worldhealth careinternational organizationinfluence1997HelsinkiSTAKESHein200389089028Hein, WolfgangKohlmorgen, LarsGlobalisation, Global Health Governance and National Health Politics in Developing Countries. An Exploration Into the Dynamics of InterfacesSchriften des Deutschen bersee-Instituts Hamburg602003HamburgDeutsches bersee Institut(e.g. Lee and Goodman, 2002, Koivusalo and Ollila, 1997, Hein and Kohlmorgen, 2003). Regarding the supranational guidance of health care systems three IGOs can be identified being particularly engaged: the World Health Organisation (WHO) as the main and formally legitimised IGO to deal with the matter; the World Bank as the challenger of the WHOs role as the global health organisation ADDIN EN.CITE Koivusalo199737376Koivusalo, MeriOllila, EevaMaking a Healthy WorldHealthy Worldhealth careinternational organizationinfluence1997HelsinkiSTAKESLee20023893895Lee, KelleyGoodman, HilaryLee, KelleyBuse, KentFustukian, SuzanneGlobal policy networks: the propagation of health care financing reform since the 1980sHealth Policy in a Globalising World97-119health careglobalisationhealth care financing2002CambridgeCambridge University Press(Koivusalo and Ollila, 1997, Lee and Goodman, 2002); and the Organisation for Economic Cooperation and Development (OECD) as a rather new but quite ambitious actor in health policy ADDIN EN.CITE Deaconforthcoming9609605Deacon, BobKaasch, AlexandraMahon, RianneMcBride, StephenThe OECD's Social and Health Policy: Neo-liberal stalking horse or balancer of social and economic objectivesThe OECD and Global GovernanceforthcomingUBC Press(Deacon and Kaasch, forthcoming). This multiplicity of actors has been described by Deacon ADDIN EN.CITE Deacon20078178176Deacon, BobGlobal Social Policy and Governance2007LondonSage(2007) as overlapping and competing agencies in social policy, and he demonstrates how different IGOs with associated epistemic communities and other actors stand for different social policy models. This results in global social policy discourses that somewhat parallel national social policy debates. At the same time, these global discourses potentially impact on the decisions taken by the member states governments. It is in this context that this paper asks: What are the implications of three IGOs being engaged in the same dimension of global social policy (the guidance of national health care systems) for global health governance? The findings presented are a part of ongoing PhD research on global health policy and governance concerning the guidance of national health care systems.
After (1) an introduction into global health policy and governance, the paper proceeds in three analytical questions: (2) What are the IGOs respective mandates for engaging in the guidance of national health care systems? These mandates are analysed by taking into account the organisations Constitution (WHO), respective Articles of Agreement (World Bank), respective Convention (OECD); as well as their websites ( HYPERLINK "http://www.who.org" www.who.org; HYPERLINK "http://www.worldbank.org/hnp" www.worldbank.org/hnp; HYPERLINK "http://www.oecd.org/health" www.oecd.org/health), and their more recent strategic outlines for the current and future work on health care systems (particularly the World Banks new health strategy ADDIN EN.CITE World Bank2007939327World Bank, Healthy Development. The World Bank Strategy for Health, Nutrition, and Population Results2007April 24, 2007Washington D.C.World Bank(World Bank, 2007); WHO global health agenda ADDIN EN.CITE WHO2006717127WHO, Engaging for Health. Eleventh General Programme of Work 2006-2015. A Global health Agenda2006GenevaWHO(WHO, 2006a); and the OECD health updates ( HYPERLINK "http://www.oecd.org/health/update" www.oecd.org/health/update)). (3) What is the content of their policy advice or models? The organisations opinions about health care systems are investigated by comparing their models as described in the WHOs World Health Reports and other publications ADDIN EN.CITE WHO20002particularly 227WHOThe World Health Report 2000: Health Systems: Improving Performance2000GenevaWHOMurray20036628Murray, Christopher J. L.Evans, David B.Health Systems Performance Assessment: Debates, Methods and Empiricism2003GenevaWHOWHO20033327WHOWorld Health Report 2003: Shaping the future2003GenevaWHO(particularly WHO, 2000, Murray and Evans, 2003, WHO, 2003), the World Banks World Development Reports ADDIN EN.CITE World Bank199313particularly 1327World Bank, World Development Report 1993: Investing in Health1993Oxford, New York et al.Oxford University Press/ World BankWorld Bank2003141427World Bank, World Development Report 2004: Making Services Work for Poor People2003WashingtonOxford University Press/ World Bank(particularly World Bank, 1993, World Bank, 2003), and the old and new HNP sector strategy paper ADDIN EN.CITE World Bank2007939327World Bank, Healthy Development. The World Bank Strategy for Health, Nutrition, and Population Results2007April 24, 2007Washington D.C.World BankWorld Bank19978827World Bank, Health, Nutrition, and Population Sector Strategy Paper1997(World Bank, 2007, World Bank, 1997); and the final report of the OECD health project ADDIN EN.CITE OECD2004414127OECDThe OECD Health Project. Towards High-Performing Health Systems2004ParisOECD(OECD, 2004). And (4) What are their resources and means to provide such guidance and to disseminate their ideas? The dissemination strategies are studied by comparing the activities of the international organisations as presented at their websites. Concluding, (5) the findings are discussed resulting in some conclusions on the current global governance in the guidance of national health care systems. Some of the findings have been checked by interviews undertaken with staff of the three IGOs.
1) Global health policy and governance
The discussion of this paper is situated in a very particular understanding of global health policy and governance. However, global health can have many meanings and dimensions. It is used to refer to health issues of international or global concern like the cross-border spread of diseases; or epidemics causing migration flows or demographic problems. Many health problems are global in the sense of representing challenges to the global community as a whole, all in nature, cause and effect ADDIN EN.CITE Kohlmorgen20039469465Kohlmorgen, LarsHein, WolfgangHein, WolfgangKohlmorgen, LarsIntroductionGlobalisation, Global Health Governance and National Health Politics in Developing Countries. An Exploration into the Dynamics of Interfaces15-292003HamburgDeutsches bersee Institut (DI)(Kohlmorgen and Hein, 2003). Global health is also an expression for the various interconnections between globalisation and health. Lee et al. ADDIN EN.CITE Lee2002201:520128Lee, KelleyBuse, KentFustukian, SuzanneHealth Policy in a Globalising Worldhealth carehealth policyglobalisation2002CambridgeCambridge University Press(2002:5) see global health emerging as the causes or consequences of a health issue circumvent, undermine or are oblivious to the territorial boundaries of states and, thus, beyond the capacity of states to address effectively through state institutions alone, and also it can be concerned with factors that contribute to changes in the capacity of states to deal with the determinants of health ADDIN EN.CITE Kickbusch2000884see also 88417Kickbusch, IlonaThe development of international health policies - accountability intact?Social Science & MedicineSocial Science & Medicine979-989512000Hein200389089028Hein, WolfgangKohlmorgen, LarsGlobalisation, Global Health Governance and National Health Politics in Developing Countries. An Exploration Into the Dynamics of InterfacesSchriften des Deutschen bersee-Instituts Hamburg602003HamburgDeutsches bersee Institut(see also Kickbusch, 2000, Hein and Kohlmorgen, 2003). Since the concept of globalisation has broadened up to including forms of political globalisation ADDIN EN.CITE Held20028168165Held, DavidMcGrew, AnthonyHeld, DavidMcGrew, AnthonyIntroductionGoverning Globalisation. Power Authority and Global Governance1-21globalisationglobal governance2002CambridgePolity Press(Held and McGrew, 2002), the link is less on the negative effects of globalisation on health; and this paper is not on the forms of economic globalisation impacting on national welfare states including health care systems. Lee et al. ADDIN EN.CITE Lee2002201:12f20128Lee, KelleyBuse, KentFustukian, SuzanneHealth Policy in a Globalising Worldhealth carehealth policyglobalisation2002CambridgeCambridge University Press(2002:12f) even state that it may eventually lead to the development of global-level policy-making.
Accordingly, global health for the purpose of this paper refers to one dimension of the concept of global social policy and governance. Following Deacon ADDIN EN.CITE Deacon20078178176Deacon, BobGlobal Social Policy and Governance2007LondonSageDeacon199736366Deacon, BobHulse, MichelleStubbs, PaulGlobal Social Policy: International Organizations and the Future of WelfareGlobal Social Policyglobal social policysocial policyinternational organizationwelfare stateinfluence1997LondonSAGE(2007, , 1997) and Orenstein ADDIN EN.CITE Orenstein200581881817Orenstein, MitchellThe New Pension Reform as Global PolicyGlobal Social Policy522005(2005), global health policy is understood as the policies, mechanisms, and procedures used by IGOs and other actors (like non-governmental organisations, civil society organisations, business, medical association, etc.) on the one hand to influence and guide national health policy; and on the other hand to provide for a global health policy by the means of global redistribution, regulation, and the guarantee of health-related rights. While it is always difficult to clearly distinguish these different forms, the focus is on the guidance of national health care systems through one specific type of actor, namely IGOs.
Trying to understand the supranational guidance of national health care systems requires the combination of global health policy (as the content of policy advice), and global health governance (as the activity and power constellation of actors beyond the nation state). Dodgson and Lee ADDIN EN.CITE Dodgson2002715:101f7155Dodgson, RichardLee, KelleyWilkinson, RordenHughes, SteveGlobal Health Governance: a conceptual reviewGlobal Governance. Critical Perspectives92-110health careglobal governanceglobalisationmappingactors2002London/ New YorkRoutledge(2002:101f) describe the task of designing and building a system of global health governance, [] requir[ing] identification of the key actors and their contribution to such a system and add that this must recognise the diversity and dynamic nature of global health, that, in turn, produces governance mechanisms that may vary with the nature of the health issue, and the political and economic priorities given at any given time.
Describing, and even identifying, all the actors taking part in different forms of global health governance is an impossible task. Concerning the guidance of national health care systems only, still quite a number of IGOs and other actors can be found. The focus of this paper is on three of them: the WHO, the World Bank (in the form of the International Bank of Reconstruction and Development (IBRD) and the International Development Association (IDA)), and the OECD. The choice of these three IGOs is straightforward: The WHOs and the World Banks respective roles in global health policy and governance have been subject to other literature ADDIN EN.CITE Lee2002389e.g. 3895Lee, KelleyGoodman, HilaryLee, KelleyBuse, KentFustukian, SuzanneGlobal policy networks: the propagation of health care financing reform since the 1980sHealth Policy in a Globalising World97-119health careglobalisationhealth care financing2002CambridgeCambridge University PressKoivusalo199737376Koivusalo, MeriOllila, EevaMaking a Healthy WorldHealthy Worldhealth careinternational organizationinfluence1997HelsinkiSTAKES(e.g. Lee and Goodman, 2002, Koivusalo and Ollila, 1997); and recently they have been described as the two Ministries of Health at the global level ADDIN EN.CITE Deacon20078178176Deacon, BobGlobal Social Policy and Governance2007LondonSage(Deacon, 2007). The OECD has recently emerged as an increasingly important health actors, also challenging the WHOs role to some extent ADDIN EN.CITE Deaconforthcoming960see 9605Deacon, BobKaasch, AlexandraMahon, RianneMcBride, StephenThe OECD's Social and Health Policy: Neo-liberal stalking horse or balancer of social and economic objectivesThe OECD and Global GovernanceforthcomingUBC Press(see Deacon and Kaasch, forthcoming). However, also for example the International Labour Organisation (ILO) does provide some guidance and disseminates ideas through its social security conventions and activities, particularly on social health insurance. The International Finance Corporation (IFC), the private sector lending arm of the World Bank Group, is increasing its work on health. The World Trade Organisation (WTO) agreements ADDIN EN.CITE Koivusalo2003912see for example 91217Koivusalo, MeriThe Impact of WTO Agreements on Health and Development PoliciesGASPP Policy BriefGASPP Policy Brief3Jan 20032003(see for example Koivusalo, 2003), as well as the surveillance activities of the International Monetary Fund (IMF) potentially impact on health. There are, further, funds like the Global Fund to Fight AIDS, Tuberculosis, and Malaria ADDIN EN.CITE Bartsch2005961see for example 96147Bartsch, SonjaThe Global Fund to Fight Aids, Tuberculosis and Malaria: Establishment, Current Issues and Future ChallengesSalzburg Seminar on the Governance of Health20055-8 December 2005OSI/Yale University/Temple University, Salzburg(see for example Bartsch, 2005); as well as various other actors (e.g. civil society organisations, business actors, and medical associations). And private foundations like the Bill and Melinda Gates Foundation are increasingly having a say in global health matters.
2) International health organisations with different mandates
How does it come there are several IGOs engaging in the guidance of national health care systems? And what are the particular roles of the WHO, the World Bank, and the OECD respectively? A look at the general characteristics of IGOs, as well as on the organisations mandates provides an idea about this.
IGOs are often considered particularly important actors in global policies. What make them such important actors? Firstly, they play a crucial role as organisations built by and in their decision-making bodies comprised of national governments. Amongst other things they execute international agreements between states, make global authoritative decisions, work intensively on domestic governance issues, and so on; while they are autonomous actors themselves ADDIN EN.CITE Barnett199988988917Barnett, Michael N.Finnemore, MarthaThe Politics, Power, and Pathologies of International OrganizationsInternational Organisation699-7325341999Barnett20049629626Barnett, MichaelFinnemore, MarthaRules for the World. International Organizations in Global Politics2004Ithaka, LondonCornell University Press(Barnett and Finnemore, 1999, , 2004). Secondly, they make rules, [] create and define new categories of actors [], create new interests for actors [], and transfer models of political organization around the world ADDIN EN.CITE Barnett1999889:69988917Barnett, Michael N.Finnemore, MarthaThe Politics, Power, and Pathologies of International OrganizationsInternational Organisation699-7325341999(Barnett and Finnemore, 1999:699). Simmons/Martins ADDIN EN.CITE Simmons20018401938405Simmons, Beth A.Martin, Lisa L.Carlsnaes, WalterKisse, ThomasSimmons, Beth A.International Organizations and InstitutionsHandbook of International Relations192-2112001Sage(2001) state that international organisations deserve attention at least in part because they have agency, agenda-setting influence and potentially important socializing influences. Their basic legitimisation and important position, however, does not prevent them from often produc[ing] undesirable and even self-defeating outcomes repeatedly, without punishment much less dismantlement ADDIN EN.CITE Barnett1999889:70088917Barnett, Michael N.Finnemore, MarthaThe Politics, Power, and Pathologies of International OrganizationsInternational Organisation699-7325341999Vaughan1999839see also 83917Vaughan, DianeThe Dark Side of Organizations: Mistake, Misconduct, and DisasterAnnual Review of Sociology271-305251999(Barnett and Finnemore, 1999:700, see also Vaughan, 1999) IGOs usually try to sell their work as impersonal, technocratic, and neutral as not exercising power but instead as serving others ADDIN EN.CITE Barnett1999889:70888917Barnett, Michael N.Finnemore, MarthaThe Politics, Power, and Pathologies of International OrganizationsInternational Organisation699-7325341999(Barnett and Finnemore, 1999:708). IGOs tend to expand their work to further policy fields and issues that overlap with some part of their original work focus. As many of them do that, this results in considerable overlaps and competition as described by Deacon ADDIN EN.CITE Deacon20078178176Deacon, BobGlobal Social Policy and Governance2007LondonSage(2007) for global social policy. At the same time, IGOs usually do not die, thus they do not fully replace each other. However, the support of the member states to particular programmes may be increased or decreased substantially. Thus, different IGOs can emerge being more or less important or powerful actors in particular policy fields or topics in different times, with implications for respective constellations of global governance and related predominant policy advice. These characteristics of international organisations and their work also apply when it concerns health policy and governance. While, as has been described above, there is quite a number of IGOs and other actors engaged in guiding and influencing national health policy, this paper focuses on three of the most important ones: the WHO, the World Bank, and the OECD.
Actually, it is only the WHO that features something like an explicit mandate for guiding health care systems. The WHO is a truly global organisation with almost universal membership. The organisations general objective is the attainment by all people of the highest possible level of health (WHO Constitution). Among the specified functions are the directing and coordination of international health work (Article 2 a, Constitution); and to assist governments in strengthening their health services (Article 2 c, Constitution). In the course of the preparation of the World Health Report 2000 ADDIN EN.CITE WHO20002227WHOThe World Health Report 2000: Health Systems: Improving Performance2000GenevaWHO(WHO, 2000), the WHO attempted to develop for itself a new role, particularly in the guidance of health care systems. After the reports publication, it turned out that the WHO had failed dramatically. Particularly, some high-income countries heavily criticised the indicators and ranking used to evaluate the performance of health care systems in WHO member states. ADDIN EN.CITE Ollila200276876817Ollila, EevaKoivusalo, MeriThe World Health Report 2000: World Health Organization health policy steering off course-changed values, poor evidence and lack of accountabilityInternational Journal of Health ServicesInternational Journal of Health Services503-143232002Hkkinen200093593527Hkkinen, UntoOllila, EevaThe World Health Report 2000. What does it tell us about health systems? Analyses from Finish ExpertsThemes from Finland//20002000FinlandSTAKES(Ollila and Koivusalo, 2002, Hkkinen and Ollila, 2000) As a consequence, work on health care systems decreased significantly, due to limited political and financial support to the WHO work as a whole, and health care systems in particular. The general call for strengthening health care systems, nevertheless, remains an important WHO statement. Perhaps, the work will be increasing now that the new Secretary-General Margaret Chan introduced the Global Health Agenda ADDIN EN.CITE WHO2006717127WHO, Engaging for Health. Eleventh General Programme of Work 2006-2015. A Global health Agenda2006GenevaWHO(WHO, 2006a) stressing the health care systems as one of the WHOs priority areas; as well as creating a new cluster on Health Systems and Services headed by Anders Nordstrm. But more likely are continued statements on the importance of health care systems and comprehensive approaches while not being able to allocate sufficient resources or more concrete interest to health care systems within the WHO.
The World Bank also with a universal membership, but with different members in the form of donor and client countries , does not have any official mandate for health. According to its original mandate the World Bank should only be concerned with economic matters; and if other fields come into focus, legitimisation of activity should only be on economic grounds. ADDIN EN.CITE Koivusalo199737see 376Koivusalo, MeriOllila, EevaMaking a Healthy WorldHealthy Worldhealth careinternational organizationinfluence1997HelsinkiSTAKES(see Koivusalo and Ollila, 1997) This however, is not the case for health. The HNP Sector Strategy of 1997 ADDIN EN.CITE World Bank19978827World Bank, Health, Nutrition, and Population Sector Strategy Paper1997(World Bank, 1997) recognised the political dimensions of reforms; and also the new Health Sector Strategy paper is far from purely economic reasoning ADDIN EN.CITE World Bank2007939327World Bank, Healthy Development. The World Bank Strategy for Health, Nutrition, and Population Results2007April 24, 2007Washington D.C.World Bank(World Bank, 2007). The reason for this political engagement (policy advice) is the Banks understanding of development as a holistic and multidimensional process that focuses on people in the societies in which it operates ADDIN EN.CITE Ruger2005956:6195617Ruger, Jennifer PrahThe Changing Role of the World Bank in Global HealthAmerican Journal of Public HealthAmerican Journal of Public Health60-709512005(Ruger, 2005:61). Compared to the WHO, the World Bank is further much better equipped with staff and financial resources; and it undertakes a huge amount of theoretical and practical work in the field.
Also, the OECD does not have a specific mandate for health; it is rather generally dedicated to improving the economic and social policies of its member states. It is further a much smaller organisation with only 30 member states; however also with a global reach considering its out-reach work. Being active in a particular policy field like health is justified by the explicit wish of its member states. For some years now, OECD member states have increasingly been interested in the OECD tackling common and specific reform issues that national governments are facing. This has led to extensive extra-budgetary contributions to the OECD Health Project, followed by the creation of a new health division. But also non-member states are addressed by OECD health policy, though much less and somewhat differently, via the OECDs Development Centre. ADDIN EN.CITE Deaconforthcoming960see 9605Deacon, BobKaasch, AlexandraMahon, RianneMcBride, StephenThe OECD's Social and Health Policy: Neo-liberal stalking horse or balancer of social and economic objectivesThe OECD and Global GovernanceforthcomingUBC Press(see Deacon and Kaasch, forthcoming)
Thus, the WHO, the World Bank, and the OECD, despite initially different mandates, do overlap concerning the actual mandate for guiding national health care systems. This is particularly for the World Bank and the OECD due to extensions of their work focus. There may be several reasons for all of them engaging in the same matter. First, there are different ministers represented in the decision-making bodies of the IGOs; for the WHO and the OECD those of health, and for the World Bank those of finance and development. Second, the different IGOs staff are dominated by different professional groups or academic backgrounds (medical professionals, economists, health economists). ADDIN EN.CITE Koivusalo199737for example 376Koivusalo, MeriOllila, EevaMaking a Healthy WorldHealthy Worldhealth careinternational organizationinfluence1997HelsinkiSTAKESLee20023893895Lee, KelleyGoodman, HilaryLee, KelleyBuse, KentFustukian, SuzanneGlobal policy networks: the propagation of health care financing reform since the 1980sHealth Policy in a Globalising World97-119health careglobalisationhealth care financing2002CambridgeCambridge University Press(for example Koivusalo and Ollila, 1997, Lee and Goodman, 2002) And third, they have a somewhat different focus as concerns countries addressed in their theoretical and practical work. All of this does play some role in such processes; however, it is also shifting political concerns and topics that makes IGOs more or less engage in particular issues. As a consequence, also the work of IGOs concerning health care systems, overall, has increased. A division of labour does only seem to work to a limited extent; even though there are attempts, by all three organisations to focus their work.
Thus, although provided with different original mandates, there are indeed, at least two, if not three with the OECD, global ministries of health, all engaged in the guidance of national health care systems. That is a significant overlap but is there any sort of competition as well? Studies on the global discourse on pensions ADDIN EN.CITE Deacon199736e.g. 366Deacon, BobHulse, MichelleStubbs, PaulGlobal Social Policy: International Organizations and the Future of WelfareGlobal Social Policyglobal social policysocial policyinternational organizationwelfare stateinfluence1997LondonSAGE(e.g. Deacon et al., 1997) have shown that different international organisations and associated epistemic communities promote different types of pension systems to be implemented in member states or client countries asking for support. Is that the case regarding health care systems as well?
3) Policy models (health care systems)
In order to being able to provide their member states with guidance or support to their health care systems, IGOs need to undertake some sort of research activity, resulting in the production of knowledge as background to more specific policy advice. In nature and activity this crosses the lines to research done at universities and other research institutions, and it is, indeed, an issue for IGOs to produce high-quality, reliable knowledge. When it concerns their potential influence (see also next chapter on dissemination) this knowledge has been termed ideas in the social policy literature. Following McNeill ADDIN EN.CITE McNeill20054244245McNeill, DesmondStone, DianeMaxwell, SimonPower and Ideas. Economics and global development policyGlobal Knowledge Networks and International Developmentideaseconomicsnetworkdeveloping countries2005Oxon, New YorkRoutledgeMcNeill2005424584245McNeill, DesmondStone, DianeMaxwell, SimonPower and Ideas. Economics and global development policyGlobal Knowledge Networks and International Developmentideaseconomicsnetworkdeveloping countries2005Oxon, New YorkRoutledge(2005) ideas are collective images that influence policy, here in the sense of knowledge produced in IGOs that shapes national health policy decision making. More specifically, Emmerji et al. ADDIN EN.CITE Emmerji200588688617Emmerji, LouisJolly, RichardWeiss, Thomas G.Economic and Social Thinking at the UN in Historical PerspectiveDevelopment and Change211-235362ideasUN2005(2005) distinguish between normative ideas for example what a health care system should look like and causal ideas i.e. more operational motives about what strategy will have the desired result or what tactics will achieve a particular strategy ADDIN EN.CITE Emmerji2005886:21488617Emmerji, LouisJolly, RichardWeiss, Thomas G.Economic and Social Thinking at the UN in Historical PerspectiveDevelopment and Change211-235362ideasUN2005(Emmerji et al., 2005:214). Such ideas can appear as either shared or contested ideas ADDIN EN.CITE McNeill20054244245McNeill, DesmondStone, DianeMaxwell, SimonPower and Ideas. Economics and global development policyGlobal Knowledge Networks and International Developmentideaseconomicsnetworkdeveloping countries2005Oxon, New YorkRoutledge(McNeill, 2005), with different consequences regarding their power of influencing policy debates.
Before comparing the organisations respective ideas, some conceptual notes on health care systems need to be made. Health care systems are highly complex entities, comprised of various sub-systems, functions or dimensions. ADDIN EN.CITE Blank20047417416Blank, RobertBurau, ViolaComparative Health Policy2004BasingstokePalgrave Macmillan(Blank and Burau, 2004) For the purpose of this paper they are understood as elements of the broader welfare state, even though they are much more than that ADDIN EN.CITE Moran19993273276Moran, MichaelGoverning the Health Care State. A Comparative Study of the United Kingdom, the United States and Germanyhealth carecomparative perspectiveGreat Britain/UKUSAGermany1999ManchesterManchester University Press(Moran, 1999). As functions of the welfare state, they contribute to societal redistribution, and the guarantee of rights through organising (regulating) health care for a countrys population. ADDIN EN.CITE Freeman2000325see for example 3256Freeman, RichardThe Politics of Health in Europequalitative researchhealth careEurope2000ManchesterManchester University PressMoran19993273276Moran, MichaelGoverning the Health Care State. A Comparative Study of the United Kingdom, the United States and Germanyhealth carecomparative perspectiveGreat Britain/UKUSAGermany1999ManchesterManchester University PressKoivusalo200479779710Koivusalo, MeriMackintosh, MaureenHealth Systems and Commercialisation. In Search of Good SensePrepared for the UNRISD international conference on Commercialisation of Health Care: Global and Local Dynamics and Policy Responses DRAFT2004GenevaUNRISD(see for example Freeman, 2000, Moran, 1999, Koivusalo and Mackintosh, 2004). The main goals behind them are universal access/equity, quality and efficiency. For analytical purposes, health care systems are usually understood as fulfilling three main functions: financing, provision and governance. ADDIN EN.CITE Blank2004741for example 7416Blank, RobertBurau, ViolaComparative Health Policy2004BasingstokePalgrave MacmillanRothgang200587687617Rothgang, HeinzCacace, MirellaGrimmeisen, SimoneWendt, ClausThe changing role of the state in healthcare systemsEuropean Review187-21213Supp. No. 12005Freeman20003253256Freeman, RichardThe Politics of Health in Europequalitative researchhealth careEurope2000ManchesterManchester University Press(for example Blank and Burau, 2004, Rothgang et al., 2005, Freeman, 2000). Concerning these three functions, the conflicts are between public and private financing and provision, and the degree of decentralisation within the three functions. Despite the different character of health care systems, compared to some other welfare state elements like pension systems, Moran ADDIN EN.CITE Moran200029729717Moran, MichaelUnderstanding the Welfare State: The Case of Health CareBritish Journal of Politics and International RelationsUnderstanding the Welfare State135-16022welfare statehealth care2000(2000) and Bambra ADDIN EN.CITE Bambra200566666617Bambra, ClareCash Versus Services: `Worlds of Welfare`and the Decommodification of Cash Benefits and Health Care ServicesJournal of Social PolicyCash versus Services195-213342welfare statehealth care2005Bambra200568168117Bambra, ClareWorlds of welfare and the health care discrepancySocial Policy and SocietySocial Policy and Society412005(2005a, , 2005b) have shown that the type of health care system in a country more or less follow the general types of welfare states ADDIN EN.CITE Esping-Andersen199029296Esping-Andersen, GstaThe Three Worlds of Welfare Capitalismwelfare state1990Cambridge, UKPolity Press(Esping-Andersen, 1990).
How do the WHO, the World Bank, and the OECD approach health care systems and their functions? Do they differ in their ideas? All three organisations work on the basis of quite broad concepts of health care systems; taking into account the three functions of health care systems mentioned above, and even go beyond that. The organisations health related websites (the WHO website on health systems HYPERLINK "http://www.who.int/healthsystems/en/index.html" http://www.who.int/healthsystems/en/index.html; the World Banks HNP sector HYPERLINK "http://www.worldbank.org/hnp" http://www.worldbank.org/hnp; and the OECDs health website HYPERLINK "http://www.oecd.org/health" www.oecd.org/health) provide for a large number of different documents (reports, strategy papers, working papers, etc.) covering various aspects of health care systems. The WHO attempted to conceptualise the health care system as a whole in its World Health Report 2000, and follow-up work ADDIN EN.CITE Murray20036628Murray, Christopher J. L.Evans, David B.Health Systems Performance Assessment: Debates, Methods and Empiricism2003GenevaWHOWHO20002227WHOThe World Health Report 2000: Health Systems: Improving Performance2000GenevaWHO(Murray and Evans, 2003, WHO, 2000). In a much shorter version and referring to the WHOs model, the new Health strategy paper of the World Bank defines health systems as well ADDIN EN.CITE World Bank200793: Annex L9327World Bank, Healthy Development. The World Bank Strategy for Health, Nutrition, and Population Results2007April 24, 2007Washington D.C.World Bank(World Bank, 2007: Annex L). Part of the work is also on single functions like health financing, as analysed in Lee and Goodman ADDIN EN.CITE Lee20023893895Lee, KelleyGoodman, HilaryLee, KelleyBuse, KentFustukian, SuzanneGlobal policy networks: the propagation of health care financing reform since the 1980sHealth Policy in a Globalising World97-119health careglobalisationhealth care financing2002CambridgeCambridge University Press(2002); or provision (with many sub-topics like hospitals, pharmaceuticals, quality of provision); or in the context of particular global health topics like the health Millennium Development Goals (MDGs) (for example WHO ADDIN EN.CITE WHO20054427WHOHealth and the Millennium Development Goals2005GenevaWHO(2005), for the World Bank see HYPERLINK "http://go.worldbank.org/NW4ZNUZ2W0" http://go.worldbank.org/NW4ZNUZ2W0; for the OECD see HYPERLINK "http://www.oecd.org/document/37/0,3343,en_2649_201185_34087845_1_1_1_1,00.html" http://www.oecd.org/document/37/0,3343,en_2649_201185_34087845_1_1_1_1,00.html (accessed 20 June 2007), or particularly for the OECD on reform issues (e.g. increasing quality of or access to health services ADDIN EN.CITE van Doorslaer2006949417van Doorslaer, EddyMasseria, CristinaKoolman, XanderInequalities in access to medical care by income in developed countriesCMAJCMAJ17422006(van Doorslaer et al., 2006)).
Concerning the function of health care financing, all three IGOs call for rather public and centralised financing, aiming at creating the biggest pool possible. The World Health Report 2000 is characterised by the underlying ideal of a centralised public (taxation) system ADDIN EN.CITE WHO20002227WHOThe World Health Report 2000: Health Systems: Improving Performance2000GenevaWHO(WHO, 2000), while discussing barriers to having such a system in many low- and middle-income countries, and considering reform options.
The argument in favour of a single pool or a small number of pools of adequate size, and against fragmentation, concerns the financial viability of pools, the administrative costs of insurance, the balance between the economies of scale and (when there is little or no competition) the risks of capture and unresponsiveness, and the limitation of risk selection (which is a matter of efficiency as well as equity). Inefficiencies in collecting and pooling revenues reduce both the funds available for investment and for providing services, and peoples access to those services that can be financed. ADDIN EN.CITE WHO20002:113227WHOThe World Health Report 2000: Health Systems: Improving Performance2000GenevaWHO(WHO, 2000:113)
The World Bank is indifferent regarding a taxation or social insurance model. The new health strategy of the World Bank explains:
Financial risk pooling is the core function of health insurance mechanisms. Participation in effective risk pooling is essential to ensure financial protection. It is also essential to avoid payment at the moment of utilizing the services, which can deter people, especially the poor, from seeking health care when sick or injured. Each society chooses a different way of pooling its peoples financial risk to finance its health care system. Most high-income countries follow one of the two main models: the Bismarck model [] or the Beveridge model []. In most developing countries, multiple and fragmented forms of risk-pooling arrangements coexist. Population participation in risk pooling is lowest in LICs and among the poor. It is also low in MICs among the informal and self-employed population. Improving financial protection in Bank client countries requires a substantial effort to increase participation in risk pooling. ADDIN EN.CITE World Bank200793: Annex L9327World Bank, Healthy Development. The World Bank Strategy for Health, Nutrition, and Population Results2007April 24, 2007Washington D.C.World Bank(World Bank, 2007: Annex L)
This becomes even more clear taking into account a recent publication entitled Health Financing Revisited: A Practitioners Guide. Summarising, the authors state:
For low- and middle-income countries transitioning to universal coverage, general revenues and social insurance contributions are the two principal sources of public funding. Both accumulate public revenues into one or several pools. Because the critical issue is pooling, whether a social insurance or national health service system is ultimately chosen is of secondary importance.
Voluntary and community-based financing schemes can serve as pilots for countries as they seek to expand the role of prepaid health coverage schemes.
Broader risk pooling mechanisms, instead of fragmented, smaller risk pools, can contribute much toward effective and equitable financing of health coverage.
ADDIN EN.CITE Gottret2006959527Gottret, PabloSchieber, GeorgeHealth Financing Revisited. A Practioner's Guide2006WashingtonThe World Bank(Gottret and Schieber, 2006)
Other World Bank publications, however, have been criticised for putting too much emphasis on the private sector. There are certainly different voices coming out of the World Bank; and certainly there are examples of more emphasis on private health financing. However, it needs to be taken into account that the pure fact that the private sector is frequently addressed and discussed in World Bank publications is not the same as a policy prescription or recommendation in favour of private financing. In organisations with a large share of economists among staff members with a general belief in the chances provided by markets, it also has to be taken into account that there is a dimension of referring to these general beliefs in order to introduce other ideas or show to what extent the health sector is not suitable for private financing.
The OECD primarily describes and compares its member states health care systems, rather than providing theoretical models. Like the World Bank, the OECD is frequently concerned with private health insurance ADDIN EN.CITE Drechsler200550e.g. 5046Drechsler, DenisJtting, Johannes P.OECD Development Centre, Private Health Insurance in Low- and Middle-Income Countries. Scope, Limitations, and Policy Responses2005Paris: OECDColombo2004373727Colombo, FrancescaTapay, NicolePrivate Health Insurance in OECD Countries: The Benefits and Costs for Individuals and Health SystemsOECD Health Working Papers No. 15. DELSA/ELSA/WD/HEA(2004)62004ParisOECD(e.g. Drechsler and Jtting, 2005, Colombo and Tapay, 2004), however, the conclusion is usually that private health insurance cannot be the panacea to financing constraints. ADDIN EN.CITE Deaconforthcoming960see also 9605Deacon, BobKaasch, AlexandraMahon, RianneMcBride, StephenThe OECD's Social and Health Policy: Neo-liberal stalking horse or balancer of social and economic objectivesThe OECD and Global GovernanceforthcomingUBC Press(see also Deacon and Kaasch, forthcoming)
Some OECD countries have taken steps to reduce the burden of health costs on public financing systems. Patterns are different across the OECD. In some countries, patient cost sharing has increased as a result of policy changes. And in some of these countries, this has been accompanied by growth in private health insurance. Although in some cases these efforts have succeeded in reducing the public finance burden, the impact of such initiatives on total spending has been minimal. ADDIN EN.CITE OECD200441:834127OECDThe OECD Health Project. Towards High-Performing Health Systems2004ParisOECD(OECD, 2004:83)
As with the ideas on the financing function, comparing the approaches of the three IGOs to the function of service provision quite a common prescription emerges: a mix of public and private providers, and rather decentralised service provision ADDIN EN.CITE WHO20054e.g. 427WHOHealth and the Millennium Development Goals2005GenevaWHOWHO20002227WHOThe World Health Report 2000: Health Systems: Improving Performance2000GenevaWHOWorld Bank2003141427World Bank, World Development Report 2004: Making Services Work for Poor People2003WashingtonOxford University Press/ World BankOECD2004414127OECDThe OECD Health Project. Towards High-Performing Health Systems2004ParisOECD(e.g. WHO, 2005, WHO, 2000, World Bank, 2003, OECD, 2004). Competition among providers is considered to ensure quality. For the WHO it is less a question about if public or private providers are the better option, but about their performance:
Good policy needs to differentiate between providers (public or private) who are contributing to health goals, and those who are doing damage, and encourage or sanction appropriately. Policies to change the balance between providers autonomy and accountability need to be monitored closely in terms of their effect on health, responsiveness and the distribution of the financing burden. ADDIN EN.CITE WHO20002:xv; own emphasis227WHOThe World Health Report 2000: Health Systems: Improving Performance2000GenevaWHO(WHO, 2000:xv; own emphasis)
The definition of health care systems in the World Banks new strategy paper ADDIN EN.CITE World Bank200793 Annex L: 1699327World Bank, Healthy Development. The World Bank Strategy for Health, Nutrition, and Population Results2007April 24, 2007Washington D.C.World Bank(World Bank, 2007 Annex L: 169) similarly states: Public and private health service provision is the most visible product of the health care system. And in its World Development Report 2004 on services, it says: There is no presumption that one type of provider public, for-profit, or not-for-profit is likely to be better than any other. ADDIN EN.CITE World Bank200314:1511427World Bank, World Development Report 2004: Making Services Work for Poor People2003WashingtonOxford University Press/ World Bank(World Bank, 2003:151) While the final report of the OECD health project does not primarily focus on the provision function, but more on financing and specific topics, the background to this is the acceptance of different forms of provision in the different OECD member states; without judgement or general recommendation to move towards more private or public ADDIN EN.CITE OECD2004414127OECDThe OECD Health Project. Towards High-Performing Health Systems2004ParisOECD(OECD, 2004).
And also strong and effective government regulation in health care systems is regarded important by all organisations ADDIN EN.CITE WHO20002particularly 227WHOThe World Health Report 2000: Health Systems: Improving Performance2000GenevaWHOWorld Bank2007939327World Bank, Healthy Development. The World Bank Strategy for Health, Nutrition, and Population Results2007April 24, 2007Washington D.C.World Bank(particularly WHO, 2000, World Bank, 2007). This regulatory role per se, however, has only been discussed in the World Health Report 2000; other than that the important role of governments in regulating health care systems is usually discussed in the context of health care financing and provision. World Bank publications, however, also address the problem of failing regulatory capacity by states because they are weak or corrupt; at the same time as they discuss market failures in health. It is, therefore, not about showing that the state should not be in charge of the overall guidance of the health care system. ADDIN EN.CITE World Bank200314see for example 1427World Bank, World Development Report 2004: Making Services Work for Poor People2003WashingtonOxford University Press/ World Bank(see for example World Bank, 2003) The OECD does not explicitly engage in a discussion about the general role of government, certainly due to the fact that its member states are characterised by quite highly-developed health care systems with, in most cases, a strong role of the state overall.
Summarising, health care systems are approached in a comprehensive way by all three IGOs. And all of them acknowledge and struggle with the complexity of health care systems. The guidance of health care systems is by none of them tackled in a one-size-fits-all way. There are some general ideas characteristic to the work of all of the WHO, the World Bank, and the OECD alike: (1) The biggest pool possible when it concerns the financing function (though no clear preference regarding a taxation system or one of social insurance), in order to ensure equal access and social security through the health care system. (2) Other health care system goals like efficiency and quality should be approached by allowing competition between different (public and private) providers. (3) Strong government regulation is indispensable, however there is also a concern particularly in the World Bank about weak and corrupt governments, with the consequence of also checking the potential gains of the private or not-for-profit sector when supporting development in health.
4) Dissemination
Given the situation of three IGOs being engaged in guiding national health care systems, and coming up with rather similar policy models we have ended up with overlapping agencies, but competing? Perhaps it is their dissemination strategies and resulting power of influencing national policy making that makes the difference?
Talking about dissemination strategies, and the potential influence of IGOs like the WHO, the World Bank, and the OECD, is not talking about particularly strong or powerful means at their disposal, like binding treaties, or delegation of competences to a supranational level. Rather, it is about the potential influence through the dissemination of ideas. We have just discussed the content of such ideas concerning health care systems. Some argue that ideas in order to be influential have to provide solutions for problems on the national level ADDIN EN.CITE Beyeler2004338e.g. 3385Beyeler, MichelleArmingeon, KlausBeyeler, MichelleIntroduction: A Comparative Study of the OECD and European Welfare StatesThe OECD and European Welfare States1-12diffusionOECDEuropewelfare statecomparative perspective2004CheltenhamEdward Elgar(e.g. Beyeler, 2004), or that they need to harmonise with the underlying values and norms of a society ADDIN EN.CITE Hall1999855e.g. 85528Hall, P.The Political Power and Economic Ideas: Keynesianism Across Nations1999Princeton, NJPrinceton University PressSikkink19916466466Sikkink, KathrynIdeas and Institutions. Developmentalism in Brazil and Argentina1991Ithaca/ NY, LondonCornell University Press(e.g. Hall, 1999, Sikkink, 1991). On the other hand, Kickbusch ADDIN EN.CITE Kickbusch2000884:98188417Kickbusch, IlonaThe development of international health policies - accountability intact?Social Science & MedicineSocial Science & Medicine979-989512000(2000:981) states that states were socialized to accept norms, values and perceptions of interest with regard to both international and national health policy by an international organisation (original emphasis). The argumentation in this paper rests upon the assumption that, on the one hand, the foundation and existence of IGOs and supranational initiatives is an expression for a desire of nation states to jointly react to health challenges; and also a site of powerful interaction between nation states. On the other hand, it is assumed that once having emerged those different actors build an independent system that also develops ideas not directly connected to a concrete call for an international answer to a specific (national) problem and that they are also part of framing the policy agenda. The focus of this paper is less on the link between the IGOs and their member states in terms of actual influence, but more on the dissemination means or strategies from the side of the IGOs.
Ideas in the WHO, the World Bank, and the OECD are developed in different settings and disseminated in various ways. All organisations have been running programmes and projects on different health issues: the WHO, for example programmes on health financing policy or on national health accounts; the OECD continues its work from the OECD health project, for example on health care delivery; and the World Bank is engaged in its projects in various client countries. The WHO and OECD programmes, as well as of the research activities of the World Bank, result in numerous publications: in the form of major reports like the World Health Reports of 2000 and to some extent 2003, World Development Reports, particularly those of 1993 and 2004; and the report from the OECDs health project ADDIN EN.CITE OECD2004414127OECDThe OECD Health Project. Towards High-Performing Health Systems2004ParisOECD(OECD, 2004). More specific analyses are presented in numerous books, and working papers that can be found on the organisations websites. Many of these publications are also done jointly between WHO, World Bank, and/or OECD; and other organisations as well.
At the same time, on the request of member states, the WHO and the OECD are undertaking assessments of single member states health care systems. The World Bank does this as well, though in a different form and context, in the context of its country projects in health. The specific power of the World Bank is that it has financial means to give directly to countries and programmes. This financial power, as well as the request of member states of health care system evaluation leads to another activity of the organisations the development of tools for health care system performance assessment. The WHO has developed an analytical framework in its World Health Report 2000, that was however strongly criticised because of the indicators it introduced and the resulting ranking of health care systems ADDIN EN.CITE Hkkinen2000935e.g. 93527Hkkinen, UntoOllila, EevaThe World Health Report 2000. What does it tell us about health systems? Analyses from Finish ExpertsThemes from Finland//20002000FinlandSTAKES(e.g. Hkkinen and Ollila, 2000). The OECD has been getting more resources to develop its work on health, and increasingly integrates health care systems in its general multilateral surveillance mechanism, and in its data projects in health ADDIN EN.CITE Deaconforthcoming9609605Deacon, BobKaasch, AlexandraMahon, RianneMcBride, StephenThe OECD's Social and Health Policy: Neo-liberal stalking horse or balancer of social and economic objectivesThe OECD and Global GovernanceforthcomingUBC Press(Deacon and Kaasch, forthcoming). Such inequalities between IGOs in financial terms, but also concerning support for specific tasks, are strongly related to member states interests.
Further, the WHO, and particularly the OECD understand themselves as platforms for exchange between national policy-makers on best practices, reform models, and so on. This is an expression of the desire of member states to jointly react to health challenges, as well as share experiences. The OECD provides a setting where governments can compare policy experiences, seek answers to common problems, identify good practice and co-ordinate domestic and international policies. It is a forum where peer pressure can act as a powerful incentive to improve policy. ADDIN EN.CITE OECD200534:7346OECDThe OECD - Organisation for Economic Cooperation and Development2005www.oecd.org(OECD, 2005:7) Also the WHO, to some extent, provides such settings, for example at the European regional level through its Futures Fora Programme. The World Bank fulfils this function through its World Bank Institute. Such platforms for the member states are at the same time platforms for the IGOs to disseminate ideas, particularly by setting the agenda, providing specific reports or teaching materials, or inviting particular experts.
The organisations are weak concerning legal power. The WHO and the OECD activity or meetings can, theoretically, result in international agreements. The OECD mentions its potential to implement soft law [] and [that it] can on occasion lead to formal agreements and treaties. ADDIN EN.CITE OECD200534:7346OECDThe OECD - Organisation for Economic Cooperation and Development2005www.oecd.org(OECD, 2005:7). The WHO has implemented some international health regulations. Nevertheless, such tools have not been used related to health care systems.
Summarising, to a large extent, the three IGOs use similar dissemination strategies. An insignificant difference is that of theoretical legal power of the WHO and OECD, in contrast to the World Bank. More significant is the financial power of the World Bank, particularly its options of combining loans with policy conditions. So, we are back to the questions what are the implications for global health governance in the guidance of national health care systems? Do we have overlapping agencies all doing the same or are there differences or competition as well?
5) Overlapping but competing agencies?
Global social policy and global health policy literature has shown there is a variety of global health policy actors and also overlapping and competing agencies ADDIN EN.CITE Deacon20078178176Deacon, BobGlobal Social Policy and Governance2007LondonSage(Deacon, 2007). This paper has attempted to shed some light on the implications of a global governance situation of three IGOs being engaged in the same dimension of global social policy, namely in the guidance of national health care systems.
The analysis has focused on three IGOs that are particularly important in guiding health care systems: the WHO, the World Bank, and the OECD. It has been shown that while not all of them have an original mandate for health, let alone the guidance of national health care systems, they do have actual mandates through overlapping policy fields, or the expressed wish of their respective member states to get engaged in the matter.
Following these mandates all three organisations have approached health care systems in quite a broad sense; with some variation related to the particular countries addressed. Their ideas about health care systems are significantly similar: rather public and centralised financing, a mix of public and private providers, and overall a strong role of the state in the regulation of the system. What does this mean for a characterisation of global health policy in general? I argue that in contrast to the global discourse on pensions ADDIN EN.CITE Deacon199736366Deacon, BobHulse, MichelleStubbs, PaulGlobal Social Policy: International Organizations and the Future of WelfareGlobal Social Policyglobal social policysocial policyinternational organizationwelfare stateinfluence1997LondonSAGE(Deacon et al., 1997), in health the picture is, on the one hand, more complex in terms of topics (various functions of health care systems even going beyond financing, provision and regulation, for example including health workers ADDIN EN.CITE WHO20065527WHOWorld Health Report 2006: Working together for health2006GenevaWHO(WHO, 2006b), dimensions (including also public health issues, medical questions, pharmaceuticals, etc.), and multi-disciplinarity (not just a controversy between economic and social science approaches, but including also medical and trade issues). On the other hand, the discourse on health care systems is much less characterised by controversy between the major IGOs and associated epistemic communities or other actors. There are differences in the content of the proposed policy models, but those are rather minimal and questions of scale. For example private provision or financing might be slightly more or less of an option in one organisation than in another, or rather in one publication than another (even from the same organisation); but not significantly in terms of the major message. Also, different opinions might emerge when it is about short-term interventions. Part of the discussion is also taking place under different topics (e.g. social respective private health insurance), but not necessarily coming to fundamentally different conclusions.
As far as dissemination strategies are concerned, the World Bank has the particular power of combining loans with policy prescriptions. In this regard, and due to its means in terms of number of staff, it is potentially the most powerful actor when it concerns those three organisations. Apart from this, the dissemination tools are quite similar; and all three organisations produce normative as well as causal ideas on health care systems. Additionally, collection, analysis and dissemination of data is an important activity. They further provide platforms for exchange for national policy-makers that at the same time also serve as platforms for the IGOs to define problems and solutions, and disseminate specific ideas.
Given such an overlap do they actually compete? For pensions systems it has been shown that different global actors compete for the right to shape global and national social policy ADDIN EN.CITE Deacon20078178176Deacon, BobGlobal Social Policy and Governance2007LondonSageDeacon199736366Deacon, BobHulse, MichelleStubbs, PaulGlobal Social Policy: International Organizations and the Future of WelfareGlobal Social Policyglobal social policysocial policyinternational organizationwelfare stateinfluence1997LondonSAGE(Deacon, 2007, Deacon et al., 1997). The same cannot be easily said for health care systems. However, neither is there some sort of a division of labour among them; so are all just doing the same, or why do we have more than one global health organisation? Different starting points due to professional background of staff members, and different ministries represented at decision-making bodies, are certainly one part of the story. But perhaps the true competition is about credibility or trustworthiness in being acknowledged as a or rather the global health organisation. While international organisations seldom die and thus do not replace each other , they can be, nevertheless, substantially restricted in particular policy areas or overall, if member states, particularly those providing large fractions of the budget or extra-budgetary payments, dislike an organisations work. While there is a degree of autonomy of IGOs, this restricts that independence and marks the underlying dependence on member states. This is certainly what has happened to the WHO in relation to both the World Bank (for middle- and low-income countries) and the OECD (for its member states, as well as some non-members). It is difficult to imagine a way forward. The argument of the WHO supposed to be the one and only IGO in the matter just because of an original mandate appears rather weak considering similar policy models and more financial power at the World Banks disposal, as well as more trust in the OECDs work. This brings us back to the general need expressed by many global health actors (as well as scholars) for more research on health care systems; and perhaps it is not even too bad having it done in many and different places in order to provide for more research on health care systems and different perspectives, contexts, and so on; as long as there is a culture of knowledge exchange, communication and collaboration where possible and appropriate.
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DRAFT, please ask before quoting. All comments welcome!
Many thanks to Bob Deacon for commenting on an earlier draft of this paper.
See HYPERLINK "http://www.ilo.org/public/english/protection/secsoc/" http://www.ilo.org/public/english/protection/secsoc/
See HYPERLINK "http://www.ifc.org/che" http://www.ifc.org/che
See HYPERLINK "http://www.theglobalfund.org/" http://www.theglobalfund.org/
HYPERLINK "http://www.gatesfoundation.org/" http://www.gatesfoundation.org/
See HYPERLINK "http://www.who.int/mediacentre/news/notes/2007/np08/en/index.html" http://www.who.int/mediacentre/news/notes/2007/np08/en/index.html; accessed 20 June 2007
See HYPERLINK "http://www.oecd.org/health" http://www.oecd.org/health
At the same time, however, another member of the World Bank Group, the International Finance Corporation (IFC) is undertaking activities in health as well; meaning financial support and advice to the private sector. So far to a very small extent but increasing. This could be a matter of concern as these projects are poorly integrated into the other activities of the World Bank; and IFC staff does not appear to have a particularly comprehensive knowledge on health care systems, but a rather narrow one with an emphasis on the business or profit goal (in contrast to the development goal).
Referring to Finnemore, M. (1996): National Interests in International Society. Ithaca, NJ: Cornell University Press.
See HYPERLINK "http://www.who.int/health_financing/en/" http://www.who.int/health_financing/en/
See HYPERLINK "http://www.who.int/nha/en/" http://www.who.int/nha/en/
See HYPERLINK "http://www.oecd.org/health/efficiency" \t "_blank" www.oecd.org/health/efficiency
See HYPERLINK "http://www.oecd.org/health/dataprojects" \t "_blank" www.oecd.org/health/dataprojects
HYPERLINK "http://www.euro.who.int/futuresfora" http://www.euro.who.int/futuresfora
HYPERLINK "http://go.worldbank.org/53LOBQ2OK0" http://go.worldbank.org/53LOBQ2OK0
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