NHS-FPX5028_GarciaMartina_Assessment1-1

1 Global Health Organizations and Health Care Model Martina Garcia Capella University NHS-FPX5028 Comparative Models of Global Health Systems Dr. Yvonne Alles October 2023

2 Global Health Organizations and Health Care Model This following executive summary will provide a high-level overview of the missions and initiatives of four major global health organizations, with an analysis of how their efforts align with the core principles defined within the World Health Organization (WHO) constitution. The executive summary will outline the structures and components of the three major health care delivery models employed globally: entrepreneurial, mandated health insurance, and national health service. Finally, there is a review of key performance indicators (KPIs) used to evaluate performance within and across these systems to assess the organization’s ability to effect change and meet their stated goals. Mission and Major Initiatives Initially proposed in 1945 by representatives from Brazil and China to the convention forming the United Nations (UN), the World Health Organization came into being April 7, 1948, through the ratification of its constitution by UN delegates as an agency of the UN. With the adoption of the core principles outlined in the WHO’s constitution preamble, it effectively defined health care as a human right of all people and elevated equitable health as a security issue, equated the importance of mental health to physical health, and prioritized the health of children (World Health Organization, n.d.-a). The following outlines the mission and major initiatives of four major global health organizations: the WHO, the United Nations Foundation (UNF), the World Bank, and the International Monetary Fund (IMF). The COVID-19 pandemic put a spotlight on the strategic challenges facing these organizations in response to a significant health care issue. First, the way in which the organizations are structured in terms of leadership and funding tends to favor wealthier nations; for example, the IMF distributed $228 billion to the seven wealthiest nations to address the pandemic, while only $8 billion to the least developed (Lederer, 2023). Another longstanding criticism of the Word Bank and IMF is that they tend to impose requirements and policies of industrialized nations, rather than working with local

4 In 1998, American entrepreneur Ted Turner donated the initial $1 billion to fund the formation of the UNF (United Nations Foundation, n.d.-b). Conceived as a strategic partner to the United Nations in support of its 17 Sustainable Development Goals (SDGs), the organization has been instrumental in mobilizing global responses to climate change and environmental crises, advocating for gender equality and reproductive justice, preserving world heritage sites, and supporting advances to fight malaria, tuberculosis, and HIV/AIDS (United Nations Foundation, n.d.-a). The UNF mission is to “advance human dignity and protect the planet through our work on transformative issues critical to humanity’s shared future” (United Nations Foundation, n.d.-b). The UNF’s current initiatives are distributed across seven domains: climate justice; girls and women; global health; data and technology; UN reform and innovation; peace, human rights, and humanitarian response; and emerging issues. Within the global health domain, focused effort is being placed on COVID-19, health equity, antimicrobial resistance, vaccinations, and family planning. Within the emerging trends domain, the UNF is addressing disparities in COVID-19 vaccination rates and setbacks within the SDGs because of the global pandemic (Roberts, 2022). For example, the rate of people who have received at least one dose of COVID-19 vaccine was 72.8% among high income countries compared to just 28.89% in low income countries (Roberts, 2022). The pre-pandemic global projection for people living in extreme poverty by 2022 was 581 million people; however, post-pandemic, that project was adjusted to 657- 676 million people, with the greatest negative impact on women and children (Roberts, 2022). The World Bank In 1944, representatives from 44 UN member countries met to develop a roadmap for global economic development, cooperation, and reconstruction, resulting in the formation of the World Bank and the International Monetary Fund, to be described later ( World Bank, n.d.-b) The World Bank’s early focus was on infrastructure projects and post-war reconstruction, taking on extreme poverty in the late 1960s as a strategic focus area ( World Bank, n.d.-b) . The mission of the world bank is “to end extreme poverty and to promote shared prosperity” (World Bank, n.d.-b). Five financial institutions

5 comprise the World Bank, using a combination of loans and grants to fund reconstruction, infrastructure, and development projects (World Bank, n.d.-b). Each government participating in the World Bank has voting rights, but additional votes are allocated based on financial contributions (Masters et al., 2023). The United States has the largest share of votes within the World Bank at 15.7% (the next highest is Japan at 7.2%) and the President of the United States is delegated the authority to nominate the president of the bank, requiring ratification by the Board of Governors (Masters et al., 2023). While each of the five institutions that comprise the World Bank set their own strategic agendas, overall, the priorities of the World Bank focus on climate change, debt reduction and poverty, food security, energy, agriculture, conflict and violence, and education (World Bank, n.d.-a). The International Monetary Fund While it was created at the same time as the World Bank and is a sub-set of the United Nations, the International Monetary Fund (IMF) operates slightly differently than its sister financial organization. The managing director of the IMF is nominated by either the Executive Board or a fund director and voted in by the entire Executive Board (International Monetary Fund, n.d.). The IMF mission is to “ achieve sustainable growth and prosperity for all of its 190 member countries … by supporting economic policies that promote financial stability and monetary cooperation, which are essential to increase productivity, job creation, and economic well-being” (International Monetary Fund, n.d.) The three main strategic focus areas of the IMF are economic surveillance and advisory consulting to reduce poverty; financing and lending; and technical assistance and training for member organizations (International Monetary Fund, 2023). The IMF does not provide direct health services but aligns its strategic focus areas to the SDGs outlined by the United Nations, provides resources to support the sustainability of governments, and builds nations’ core economic capacity to provide essential services to their populations to reduce poverty (International Monetary Fund, 2023). Alignment to the Basic Principles of the WHO Constitution

7 struggling nations (Table 1), specifically in relation to function (d) of Article 2 “to furnish appropriate technical assistance and, in emergencies, necessary aid upon the request or acceptance of Governments,” function (f) of Article 2 “to establish and maintain such administrative and technical services as may be required, including epidemiological and statistical services,” and function (i) of Article 2 “to promote, in cooperation with other specialized agencies where necessary, the improvement of nutrition, housing, sanitation, recreation, economic, or working conditions and other aspects of environmental hygiene” (World Health Organization, n.d.-a). Elements and Structure of Major Healthcare Models Most industrialized nations offer some sort of universal health coverage, other than the United States; however, models employed by those countries vary in how they are financed and whether multiple models co-exist within the country (Schneider et al., 2021). Below is a high-level outline of the structures, financing, and relationship between costs and outcomes for each model. Entrepreneurial The entrepreneurial model of health care is what is considered the private or commercial insurance model in the United States and is grounded in a market-based approach for health care delivery (Fried & Gaydos, 2012). Financing for health coverage of plan members is covered by the individual member, the employer, or a combination of both (Collins et al., 2021). In this model, health care is not considered a fundamental human right but a means of generating profit with the goal of using market competition to incentivize innovation and control costs (Schneider et al., 2021). Private pharmaceutical companies re-invest profits into research and development, including funding research at academic institutions while also generating profits for their shareholders (Frank & Ginsburg, 2017). Private insurance companies are driven to generate ever-increasing profits to meet shareholder expectations, often using strategies such as denying coverage, imposing challenging pre-authorization requirements, or underpaying reimbursements (Humble, 2023). In just the second quarter of 2021, Anthem Blue Cross Blue Shield had not paid $2.5 billion in medical while UnitedHealth, Humana,

8 CVS Health and other insurance providers generated more than $41 billion in profits in 2022 alone (Humble, 2023). The rising costs of private insurance have resulted in shifting a greater cost of health care coverage to individual members, with plan premiums directing members to use high deductible health plans, which requires individuals to pay much of their annual health care costs out of pocket before the plan coverage kicks in (Collins et al., 2020). This shift has resulted in approximately 43% of Americans either underinsured or uninsured, even with improvements in coverage from the Patient Protection and Affordable Care Act of 2020 (Collins et al., 2020). Mandated Health Insurance The mandated health insurance model, or what is termed “social health insurance” by Fried and Gaydos (2012), is an effort to support universal health care coverage. The model represents a public-private partnership to finance the system as it is primarily funded through shared contributions by the employer and the employee (Fried & Gaydos, 2012). These contributions are collected by the government and may be supplemented by general revenue from income and sales taxes (Baggio et al., 2018). Like the entrepreneurial model, the potential limitation of mandated health insurance is that it depends on a population that is employed in formal employment models that collect the payroll tax and submit it to the government or third party administrator; however, some systems, such as Switzerland and Germany, have developed an approach that enables the generated payroll tax funds collected to be redistributed to cover the health care needs of parts of society that have not had traditional or long-term, stable employment (Baggio et al., 2018). Studies have shown that that MHI or SHI have resulted in decreases to catastrophic health costs for families, decreased childhood rates of infection and failure to thrive, and improvements in obstetric care (Fried & Gaydos, 2012). National Health Service (NHS) Another form of universal health coverage is the national health service, which is financed through general revenue collected by the government and redistributed to provide basic, universal coverage across a population (Fried & Gaydos, 2012). Unlike the SHI model, a NHS does not require

10 References Abbasi K. (1999). The World Bank on world health: under fire.   BMJ (Clinical research ed.) ,   318 (7189), 1003–1006. https://doi.org/10.1136/bmj.318.7189.1003 Agency for Healthcare Research and Quality. (2015) Types of Health Care Quality Measures. https://www.ahrq.gov/talkingquality/measures/types.html Baggio, S., Dupuis, M., Wolff, H., & Bodenmann, P. (2018). Associations of lack of voluntary private insurance and out-of-pocket expenditures with health inequities. Evidence from an international longitudinal survey in countries with universal health coverage.” PLoS ONE , 13 (10): e0204666. https://doi.org/10.1371/journal.pone.0204666 Collins, S.R., Gunja, M.Z., & Aboulafia, G.N. (2020, August 19). U.S. healthcare coverage in 2020: a looming crisis in affordability . The Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-briefs/2020/aug/looming-crisis-health- coverage-2020-biennial Frank, R.G. & Ginsburg, P.B. (2017, November 13). Pharmaceutical Industry Profits and Research and Development. Health Affairs . https://www.healthaffairs.org/content/forefront/pharmaceutical-industry-profits-and-research- and-development Fried, B. & Gaydos, L.M. (2012). World health systems: challenges and perspectives (2nd ed.). Health Administration Press. Humble, W. (2023, August 10). Americans suffer when health insurers place profits over people . Pennsylvania Capital-Star. https://www.penncapital-star.com/uncategorized/americans-suffer- when-health-insurers-place-profits-over-people/ International Monetary Fund. (n.d.) About the IMF . https://www.imf.org/en/About

11 International Monetary Fund. (2023). Committed to collaboration: IMF annual report 2023. https://www.imf.org/en/Publications/AREB Lederer, E.M. (2023, June 17). UN steps up criticism of IMF and World Bank, the other pillars of the post-World War II global order. Associated Press . https://apnews.com/article/un-imf-world- bank-covid-15baf3a9e4d939dd2e085ff0aa18087a Masters, J., Berman, N., & Chatzky, A. (2023). The World Bank Group’s role in global development . Council on Foreign Relations. https://www.cfr.org/backgrounder/world-bank-groups-role- global-development Organization for Economic Cooperation and Development. (n.d.) OECD Health Statistics 2023 [Data set]. https://www.oecd.org/health/health-data.htm Roberts, M. (2022, December 20). 5 global issues to watch in 2023. United Nations Foundation. https://unfoundation.org/blog/post/5-global-issues-to-watch-in-2023/ Schneider, E.C., Shah, A., Doty, M.M., Tikkanen, R., Fields, K., & Williams, R.D. (2021). Mirror, mirror 2021. Reflecting poorly: health care in the U.S. compared to the other high-income countries. The Commonwealth Fund. https://www.commonwealthfund.org/sites/default/files/2021-08/Schneider_Mirror_Mirror_20 21.pdf United Nations Foundation. (n.d.-a) Sustainable development goals. https://unfoundation.org/what- we-do/issues/sustainable-development-goals/ United Nations Foundation. (n.d.-b) Who we are. https://unfoundation.org/who-we-are/our-mission/ World Bank. (n.d.-a) What we do . https://www.worldbank.org/en/what-we-do World Bank. (n.d.-b) Who we are . https://www.worldbank.org/en/who-we-are

13 Table 1 Alignment of Global Health Organizations to WHO Principles World Health Organization Constitution Principle 1 United Nations Foundation Priorities 2 World Bank Projects 3 International Monetary Fund Projects 4 Health is state of complete physical, mental, and social well-being. Good health and well- being $2.8 billion to address food insecurity in East Africa Five countries received funding to address climate change impact. Highest standard of health is a fundamental right regardless of race, religion, political belief, economic, or social condition. Gender equality Reduced inequalities Anti-Racism Task Force to address internal policies at World Bank Mainstreaming Gender Health of all people is fundamental to peace and security, dependent on cooperation of all people and States. Peace, justice, strong institutions $327 billion peacebuilding and refugee support for Yemen, Ukraine, Syria, etc. Zero-interest poverty reduction loans Emergency loans to Ukraine for food insecurity Promotion and protection of health is of value to all. Clean air, water, sanitation & energy $427 billion for renewable energy for hospitals in Africa Unequal development in the promotion of health and disease control is a danger to all. Zero hunger No poverty $72 billion investment in Global Crisis Response Framework 75% of capacity development targeting low-income countries The health of the child is of basic importance. Gender equality Zero hunger No poverty $300 million investment in East and South African schools for girls Fullest attainment of health is through extension of medical, psychological, and related health knowledge to all people. Quality education, sustainable communities Creation of Regional Gender Action Team to focus on reproductive justice and family planning $339 million online capacity development program, reaching >160K learners Health of people depends on informed opinion and active cooperation. Decent work & economic growth Partnerships $400 billion investment in broadband and internet infrastructure across Africa $1.3 billion investment in global IT infrastructure Governments have a responsibility to the health of their people and must provide adequate health and social measures. Industry, innovation & infrastructure East African Regional Integration team to develop public health infrastructure $39 billion emergency debt relief for governments during COVID Notes: 1 Adapted from “Constitution of the World Health Organization,” by the World Health Organization, n.d. 2 Adapted from United Nations Foundation, n.d.-b. 3 Adapted from A new era in development: annual report 2023 , by World Bank, 2023. 4 Adapted from International Monetary Fund, n.d.