Chapter 4. GlobalHealthPartnershipandFundingSystem

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1 Chapter 4 GlobalHealthPartnershipandFundingSystem BanriIto 1 Abstract Inordertoincreaseaccesstohealthservicesindevelopingcountries, therehasbeen considerableestablishmentofglobalhealthpartnerships(ghp)indevelopingcountries inrecent decades. Thispaperaimsat deepeningtheunderstandingofthedeployment situationofghpprevalentindevelopingcountries. Intheempiricalanalysis, thispaper attemptstoshowclearlywhetherthepartnershipiscarriedoutamongrecipientcountries andwithwhatkindsofattributes, viatheuseofcross-countrydata.theresultsshowthat GHPiscarriedoutincountrieswheretheperformanceofgovernanceislow, andthereis astrongandpositivecorrelationbetweenthepresenceof GHPandtheburdenof diseases. 1 GlobalSecurityResearchInstitute,KeioUniversity, Mita ,MinatoWard,Tokyo, , Japan. banri@2002.jukuin.keio.ac.jp Acknowledgements: HealthServiceand Poverty-Makinghealthservicemoreaccessibletothepoor- ofdeveloping Economies(IDE).Theauthorwouldliketothankmembersoftheresearchprojectfortheir comments. 69

2 1. Introduction Inordertoincreaseaccesstohealthserviceindevelopingcountries, thepoint concerninghowtosecurea fundresource must be debated. TheCommissionon MacroeconomicsandHealth(henceforthCMH), whichtheworldhealthorganization (henceforthwho)establishedinjanuary2000, indicatedthatitispossibletoraisethe economicgrowthratebyinjectingfundsintothehealthsectorofdevelopingcountries, andit isshownthat theinvestment effect exceedsexpense(who, 2001). TheCMH pointedoutthatthefactthatthehealthandmedicalservicesarenotfullyaccessibleto peoplelivinginpoverty, whichisthebeneficiaryofservice, asthebiggest problem causedbythefinancialdeficit ofthehealthsector. Toovercomethisproblem, efforts involvingthedevelopingcountriesthemselvesincreasinggovernmentexpenditureonthe healthsectorareinitiallycalledfor. Also, inthecmhreport, itisadvocatedthatthe governmentofeachcountry, itself, shouldinitiallyexpandthebudgetallotmenttothe healthsector. Letitbeapremisetoimplementapercentageincrease;anincreaseof1% by2015basedongnpcontrastasaconcretenumericaltargetby2007(who, 2001). Althoughsomedevelopingcountriescanattainthistarget, it isdifficult to investsourcesofrevenue, whicharegenerallyrestrictedindevelopingcountries, intothe healthsector. Basedonthefinancial situation, suppressedbyscarcetaxrevenuesand domesticandoverseasdebt, allocatingfundstothehealthsectorisverydifficult ina low-incomecountry. Therefore, foradevelopingcountrywhichsuffersfromfinancial deficiency, theroleoftheexternaldonor, whichcanburythefinancinggap, ispresumed tobeimportant. TheWHO(2001) hasarguedstronglyofthenecessityforfinancial supportanditsexpansioninalowincomecountry, enphasizingthatitisessentialthatit increasetoa27billion-dollarlevelperyearby2007anda38billion-dollarlevelperyear by2015. Meanwhile, manyglobalhealthpartnerships(henceforthghp)havebeenset upinthehealthsectorindevelopingcountriesinrecentdecades. Althoughthenumber alreadyamountstoapproximately100, that focusondifferent diseasesandcarryout differentfunctions. Althoughthepointconcerningthenatureofthetendencyshownby theactual conditionofarapidlyincreasingpartnershipisaveryinterestingresearch subject, thereislittleresearchclearlyfocusingonthispoint. Further, toanalyzewhether 70

3 thepartnerships aresupportingacountryandwithwhat kindof attributearealso interestingissues. Forexample, inthecmhreport, underthepartnershipofadonorand arecipientcountry, inorderforadevelopingcountrytoimplementsuitableinvestment management, itisindicatedthatitisasubjecttoconquerthestructuralvulnerabilityof healthandthemedical system. Inorder topromotethereexaminationofthefragile publichealthandmedicalorganizationofarecipientcountry, orunsuitableinvestment management, thereporthasclamedthatthedonorshouldensurethefundoffersubjectto stringentconditionsandwithholdlarge-scaleaidtocountrieswhichengageininefficient fund management. Therefore, there is roomto examine whether support by the partnershipisactuallyofferedtocountrieswherethereisconsiderableperformanceof leadership, accountability, andtransparencyaswellasfundmanagementability. Thispaperaimstodeepenunderstandingofthedeployment situationofthe partnershipsindevelopingcountries. Specifically, ittriestoputthepartnershipsinorder fromvarious angles inthefirst place. Sincetherearevarious approaches tosuch partnerships, mappingoutthekindofpurposeforthedevelopmentofthepartnershipwill helptheactual conditionbeunderstood. Moreover, it canalsobeclearlyshownwhat kindoforganizationhasplayedamajorroleinthehealthsectorintermsofthesubjectof theparticipatingpartnershipandthatoffunddonation. Viaempiricalanalysis, thispaper attemptstoclearlyillustratewhetherpartnershipiscarriedoutamongrecipientcountries andwithwhatkindofattributebyusingcross-countrydata. Thepointastowhetherto proceedwithdeployment accordingtothesituationof thegovernanceofarecipient country, aspointedoutbythecmhreport, andwhetherthepartnershipsuitstheneedsof arecipientcountry, isanalyzedempirically. Theresultsofthispaperaresummarizedas follows:(1)theneglecteddiseaseswerecoveredbyatleastoneormorepartnership/s whilealargenumberofghpsconcentrateonthreemajordiseases, suchashiv/aids, tuberculosisandmalaria. (2) ThecontributionoftheGatesfoundationissignificantly highfromtheviewpointoffundscaleandcoverage. (3)TheGHPisimplementedina countrywherethereislowperformanceofgovernance, andthereisastrongandpositive correlationbetweenthepresenceofghpandtheburdenofdiseases. Thispaperisorganizedasfollows. Inthenextsectionwepresentgeneralfacts regardingthepartnerships. Section3describesthedatasetusedforempiricalanalysis, thespecificationofmodelandtheestimationresults, whilesection4concludes. 71

4 2. GeneralFactsofGlobalHealthPartnerships 2.1TheDefinitionofGlobalHealthPartnerships Sinceacleardefinitiondoesnotexist, partnershipsrelatedtohealthissuesin developingcountrieshavebeendealt withtodatebyvariousterms, suchasglobal HealthPartnerships(GHP), GlobalPublicPrivatePartnerships(GPPPs), GlobalHealth Initiatives(GHIs)andInternationalPublicPrivatePartnershipsforHealth(IPPPH), etc.. InaseriesofreportsaboutthepartnershipsundertakenbythehealthcenteroftheBritish collaborativerelationshipamongmultipleorganizations, inwhichrisksandbenefitsare sharedinpursuitofasharedgoal. Thefocusisonmoreformalcollaborativeventures andnot exclusivelyonpublic-privatepartnerships, althoughtheselatterconstitutethe majority. The secondcriterionis rel establishmentaimstosolvehealthproblemsofsignificancefordevelopingcountries. borders(cainesetal., 2004). ThispaperfollowstheapproachoftheDFIDstudieswhich usethetermglobalhealthpartnership. 2.2TheTrendsinGHPandBackground AsshowninTable1, whichtabulatesthenumberofannualestablishmentsof GHP, aremarkableclimbisevident, especiallyfromthesecondhalf of the1990s, peakingin2000with17newentities. AlthoughRichter (2004) pointedout that the importanceofpartnershipwasalreadyrecognizedintheunitednationsin1990, theyear 1997isshowntohavebeenanotherturningpoint intherelationbetweentheunited Nations and the business community referring to the statement of the former Secretary-General of theunitednations, Kofi Annanthat therelationshipwiththe businesscommunityisparticularlyimportant. Timeisvaluedalmost equivalentlyand USAIDSwasestablishedin1996asacollaborativeorganization, comprisingmany organizationsof theu.n. organizationsrelevant tohiv/aidsproblems; thewho, UNICEF, UNESCO, ILOandUNHCR. Thus, inresponsetothemulti-sectorapproachin 72

5 developmental policy, the number of partnerships increases rapidly in 1996 and thereafter. Table1:DistributionofGHPoverEstablishmentYear Est.year No.GHP Est.year No.GHP Source:ThePartnershipsDatabasebytheInitiativeonPublic-PrivatePartnershipsforHealth (IPPPH) 2.3TheTypologyofGlobalHealthPartnerships ThissectionputsGHPinorderfromvariousangles. Inordertounderstandthe actualconditions, thenatureofthekindofpurposeforwhichthepartnershipisbeing developedmustbemappedout. Table2showsthecumulativenumberofpartnerships overthemainobjectiveasof2003, presentedbythepartnershipsdatabase, whichwas originallycreatedbytheinitiativeonpublic-privatepartnershipsforhealth(ippph). 2 Thisdatabaseclassifiestheobjectives ofpartnershipsintothefollowing7categories:1. Product Development, 2. Improvement of Access to Health Products, 3. Global Coordination Mechanism, 4. Health Services Strengthening, 5. Public Advocacy, EducationandResearch, 6. RegulationandQualityAssurance, 7. Other. Accordingto theseclassifications, themajorityofpartnerships, 34, target thedevelopment ofnew medicines, andwhenpartnershipsaimingtoimproveaccesstoexistingmedicineare added, theyrepresent60percentormoreoftheoveralltotal. 2 This paper collects the data on GHP from the website of IPPPH; ). 73

6 Table2:DistributionofGHPoverApproach Approach No.ofGHP 1.ProductDevelopment 35 2.ImprovementofAccesstoHealthProducts 26 3.GlobalCoordinationMechanism 12 4.HealthServicesStrengthening 9 5.PublicAdvocacy,EducationandResearch 15 6.RegulationandQualityAssurance 3 7.Other 1 Source:ThePartnershipsDatabasebytheInitiativeonPublic-PrivatePartnershipsforHealth (IPPPH) Thepoint consideringwhether specificpartnerships aretargettingspecific diseasesisalsointeresting. Table3showsthecumulativenumberofGHPoveratarget diseaseorconditionasof2003. Themajorityofpartnerships, 20, areforhiv/aids, reflectingthedegreeofattentionandtheseriousnessoftheplight. Therearealsomany partnershipsforothermajordamagingdiseases, suchasmalaria(18)andtuberculosis (10). Thepartnershipfor thethreediseasesreachesahalfamongthewhole. Asfor 3 suchaschagas, humanafricantrypanosomiasis(aliassleeping sickness), leishmaniasisandmeningitis, itshowsthattheywerecoveredbyatleastone ormorepartnership/s. 4 Itisindicatedthatthestancewherebyboththepublicandprivate sectorsarecopingwiththosediseasesasamarketmechanismdoesnotfunction. 3 Thereisnoclear definitionfor neglecteddiseases. Arenownednon-governmental, cites malaria, human African trypanosomiasis(aliassleepingsickness), leishmaniasisandmeningitisasneglecteddiseases. TheWHOandthepharmaceutical industryidentifiedthefollowingparasiticdiseasesas being truly neglected: African trypanosomiasis, leishmaniasis, and Chagas disease (WHO/IFPMA, 2001). 4 Caines(2004)foundthesameresult,namelythattheselectedneglecteddiseases,12outof 15,areaddressedbyatleastoneGHP. 74

7 Table3:DistributionofGHPoverDiseasesorConditions Disease/Condition No.ofGHP Disease/Condition No. ofghp Allhumandiseasesandmedicalconditions 1 Leprosy 2 Blindness 3 LymphaticFilariasis(LF) 2 Cataract 1 Malaria 18 Chagas 2 Meningitis 2 Chemicalsafetyinformation 1 Micronutrientdeficiency 2 Communicablediseases 2 Neglecteddiseases 1 Counterfeitandsubstandarddrugs 2 Onchocerciasis(riverblindness) 4 Dengue 2 Parasiticandotherneglectedinfectiousdiseases 1 Diarrheadehydration 1 Pneumococcalvaccines 1 Digitaldivide 1 Polio 1 Diseasesofthepoor 1 Reproductivehealth 5 Guineaworm(dracunculiasis)disease 1 Schistosomiasis 1 Harmonizationofdrugapplications 1 Sexuallytransmittedinfections 7 Healthpoliciesandhealthsystems 1 Tetanus, maternalandneonatal 1 HIV/AIDS 20 Trachoma 3 HumanAfricantrypanosomiasis 4 Tuberculosis(TB) 10 HumanHookwormInfection 1 Vaccinevialmonitors 1 Injectionsafety,syringes 2 Vaccine-preventablediseasesofthepoor 5 Lassafever 1 VitaminAdeficiency 1 Leishmaniasis 3 Source:ThePartnershipsDatabasebytheInitiativeonPublic-PrivatePartnershipsforHealth (IPPPH) 2.4ParticipantsandFounderofGHPs AlthoughGHPstargetvariousdiseaseswithvariousapproaches, thequestion as tothe nature of the organizationfor the subjects havingparticipatedinsuch partnershipsremains. Table4showswhatkindoforganizationhasplayedthemajorrole in GHPs participating in the health sector. The WHOhas participated inmany partnershipsasexpected, whiletheother toptenrankingsincludefour international organizations, twou.s. Governmentorganizations, threepharmaceuticalcompaniesand a private foundation. This table demonstrates howvarious organizations have cooperativelyparticipatedinghp. 75

8 Table4:MajorParticipantsofGHP Participants Number 1WorldHealthOrganization(WHO) 43 2UnitedNationsChildren'sFund(UNICEF) 21 3WorldBank 18 4Bill&MelindaGatesFoundation 16 5USCentersforDiseaseControl&Prevention(CDC) 15 6GlaxoSmithKline(UK) 13 7UNDP/WB/WHOSpecialProgrammeforResearch&TraininginTropicalDiseases(TDR) 13 8USAgencyforInternationalDevelopment(USAID) 12 9Merck&Co.,Inc Sanofi-Pasteur(mergerofAventis-PasteurandSanofi) 9 11UKDepartmentforInternationalDevelopment(DFID) 9 12JointUnitedNationsProgrammeonHIV/AIDS(UNAIDS) 8 13LondonSchoolofHygiene&TropicalMedicine 8 14PfizerInc. 8 15MedecinsSansFrontieres(MSF) 7 16Novartis 7 17Bristol-MyersSquibbCompany 6 18CanadianInternationalDevelopmentAgency(CIDA) 6 19CarterCenter 6 20ProgramforAppropriateTechnologyinHealth(PATH) 6 Source:ThePartnershipsDatabasebytheInitiativeonPublic-PrivatePartnershipsforHealth(IPPPH) Table5:MajorFoundersofGHP Founder Number Contribution(US$) 1Bill&MelindaGatesFoundation 31 4,645,724,419 2UnitedKingdom,Governmentof 2 2,928,720,000 3France,Governmentof 3 2,664,751,427 4USAgencyforInternationalDevelopment(USAID) 5 1,539,500,000 5Italy,Governmentof 3 1,000,000,000 6Norway,Governmentof 6 808,221,757 7UnitedStates,Governmentof 2 566,420,000 8EuropeanCommission 5 563,870,813 9Canada,Governmentof 2 324,220,000 10UKDepartmentforInternationalDevelopment(DFID) 6 299,421,096 11Netherlands,Governmentof 6 265,835,059 12Spain,Governmentof 2 240,000,000 13Japan,Governmentof 1 200,000,000 14CanadianInternationalDevelopmentAgency(CIDA) 5 137,391,162 15Bristol-MyersSquibbCompany 1 115,000,000 16Sweden,Governmentof 2 107,040,000 17BillandMelindaFoundationChallengeGrant 1 100,000,000 18SwedishInternationalDevelopmentAgency(SIDA) 4 73,026,600 19EliLillyandCo. 1 70,000,000 20Merck&Co.,Inc. 1 50,000,000 Source:ThePartnershipsDatabasebytheInitiativeonPublic-PrivatePartnershipsforHealth(IPPPH) Note:Thetableisarrangedinorderofthefundscale. 76

9 Itisalsointerestingtoinvestigateabout thefunddonationorganizations. As shownintable5, afamousprivatefoundation, thebill&melindagatesfoundation, has overwhelmingly subscribed funds to many partnerships. Further, while the governmentofeachcountryoccupiesahigherrankwithinafundscale, thecontributions ofthegatesfoundationturnouttobethelargest, asshownintherightendcolumn. 5 Itis clearthatthegatesfoundationissignificantlycontributingtothedevelopmentofghp fromtheperspectiveofthescaleandcoverageoffunding. Therefore, partnershipsin whichthegatesfoundationisengaginginfunddonationsshouldbeinvestigatedin further detail. Table6indicates thenameof thepartnership, thetarget illness, the contributionamount, andtherateoftotaloccupancyofthegatesfoundationdonation relativetotheoverallpartnership. Asforthecoverage, thegatesfoundationdonatesto partnerships covering various diseases, including neglected diseases such as leishmaniasis, malaria, humanafricantrypanosomiasisandmeningitis. Further, there existsafrequenttendencyfortheamountofcontributiontoeachpartnershipofthegates Foundationtooccupythevastmajorityofthetotalinmanycases. Ofthepartnerships receivingdonationsfromthegatesfoundation, 17of29sawthelattercontributeover80 percentofthetotal.moreover, afurther11partnershipsaremanagedcompletelysolely basedoncontributions fromthegates foundation. It emergedthat inthecaseof large-scalepartnerships, likegaviorgfatm, themajorityoffundswereprovidedby donations fromnational government, whilethegates foundationwas asignificant presenceinotherpartnerships. 5 Theamountofmoneyshowsthecumulativefundscalesubscribeduntil2003,respectively, andthecommitmentoffunddonationisnotincluded. 77

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11 3. EmpiricalAnalysisofGlobalHealthPartnerships 3.1ModelSpecification TheCMHreporthasclamedthatthedonorshouldensurestringentconditions for the fundoffer andwithholdlarge-scale aidtocountries withinefficient fund management(who, 2001).Ontheotherhand, althoughghpareactuallyprogressingin various developingcountries, little has beenanalyzedconcerningthe actual GHP circumstances. It is aninterestingissuetoinvestigatewhat country-specificfactors determinetheentryofghp. Inthissection, thetypeofattributesofrecipientcountries capableofaffectingthevolumeofpartnershipactivitiesareshown. Accordingtothe CMHreport, theperformanceofleadership, accountability, andtransparencyandthe fundmanagement abilityofinvestment management areconsideredimportant factors whenreceivingtheexternalfundingsupport. Thus, thosecountry-specificfactorscanbe set asvariablesthat explainthevolumeofghppenetrationwithinthecountry. Asa hypothesis, thegoodgovernanceofarecipient countryisexpectedtohaveapositive relationwithghpentryifsupportbyghphasbeenimplementedinacountrywherethe performanceofgovernanceishigh, asproposedinthecmhreport. Intheregression analysis, it isexaminedwhether thecoefficient of governanceindexissignificantly positiveornot, aftercontrollingthecountrysize, thecapacityofthehealthsystemsand burdenofdiseases. ThedemandfactorisalsoimportantasadeterminantforGHPentry. Intuitively, it is presumedthat GHPrepresent applicablesupport incountries with considerable burdens of diseases and adverse conditions, as well as those with insufficientfundsforthehealthsector. Thus, thesefactorsareexpectedtobepositively relatedtoghpactivitiesintherecipientcountry. Sincethenumberofpartnershipsin eachcountryis a variable, the Poissonregressionmodel, whichassumes Poisson distributionfortheerrorterm, isusedintheestimationbyformulatingtheexpected number of partnershipsasanexponential functionof thecountry-specificfactorsas follows: E p i X i i exp X i wherei indexesthecountry, and X i denotesthevector of countrycharacteristics, indicatingthegovernance, countrysize, thelevel of healthsystems andburdenof 79

12 diseases. Theparametersareestimatedusingthemaximumlikelihoodestimationmethod. Sincetheestimatedcoefficientsareinterpretedas d i 1, themarginaleffector d elasticitiescanbecalculated. However, thereisconcernthattheequalizationfeatureof theconditional meanandvarianceis rarelysatisfiedbytheactual data. Sincethe varianceisobservedtooftenexceedthemeanofadiscretevariable, inadditiontothe Poissonregressionmodel, thenegativebinomial model isalsoestimatedtocopewith thisnon-equalizationproblembetweenthetwo. 6 X i i 3.2DataandSummaryStatistics Thedatausedintheestimationregardingthedeterminantofpartnershipswas obtainedfromdataonthepartnershipinvestigatedbycarlson(2004) onaspecific countrybasis. Carlson(2004) providesatabledetailingthepartnershipswhichhave enteredeachcountry, basedontheinformationonthewebsiteofeachghpasof2003. Fromthetable, thenumberofpartnershipsineachcountrycanbeusedasameasurement ofghpvolumebyindividuallycountingthem. However, it must benotedthat this measurementforthevolumeofghpactivitiesmaybeinappropriatebecausethescaleof afundisabetterproxyvariablethanthenumber, anditisdifficulttoconfirmthesedata foreachghpandcountry, duetorestrictionsofdata. Thus, inthispaper, thenumberof partnershipsisassumedtohaveastrongcorrelationwithitsfundingscale. Intheanalysis, 111nations, whichsucceededincollectingdataonthecountrycharacteristics, were selectedfromthe127nationsstudiedbycarlson(2004). Thedataonthenatureofacountryiscompiledfromvariousdatasources. Asa proxymeasurementofthekeyvariable, namelythemeasureofgovernanceinarecipient country, globalgovernanceindicatorsin2003, providedbytheworldbankinstitute, havebeenadopted. Theseindicatorscover213countriesandterritoriesandassesssix dimensionsofgovernance, namely:voiceandaccountability, politicalstabilityandthe absenceofviolence, governmenteffectiveness, regulatoryquality, ruleoflaw, andthe controlofcorruption. Theindicatorsarebasedonhundredsofvariablesandreflectthe viewsofthousandsofcitizenandsurveyrespondentsandexpertsworldwide(kaufmann 6 ForfurtherdetailsofthePoissonregressionmodelandthenegativebinomialmodel,see Hausman,HallandGriliches(1984)andCameronandTrivedi(1986), respectively. 80

13 et al., 2006). 7 This paper uses thesumof sixindices for thesedimensions as the governanceindexintheestimatedequation. Asfortheburdensofdiseases, ameasure calledthedisabilityadjustedlifeyears(daly)hasbeendevelopedbythewho. This measureincorporatesvariouskindsofdamageimposedbydiseasesandinjuries, suchas deathanddisability, andishencemoresuitablethanusingthenumberofdeathsorthe numberofinfectedpersonsasanindex, toillustratethevariousburdensofthedisease eachcountryin2002isusedasaproxyfor themagnitudeof burdenscausedbyinfectiousdiseasesinthecountry. 8 Theothernationalcharacteristics are compiledfromthe WorldDevelopment Indicators The countrysize is measuredbygdp,convertedtousdollarsatcurrentrates, andthehealthexpenditureof publicsector(percentageofgdp)isincludedintheestimationasaproxyforthemature degreeofthehealthsectorinthecountry. Summarystatisticsofthesevariablesandthe correlationmatrixarepresentedintables7and8, respectively. Table7:SummaryStatistics Variable Mean Std.Dev Min Max ThenumberofGHP GovernanceIndex Burdenofinfectiousdiseases(1,000DALY) Healthexpenditurebypublic(%ofGDP) GDPcurrentUSdollarsinlog Table8:CorrelationMatrix [1] [2] [3] [4] [5] [1] ThenumberofGHP 1 [2] GovernanceIndex [3] Burdenofinfectiousdiseases(1,000DALY) [4] Healthexpenditurebypublic(%ofGDP) [5] GDPcurrentUSdollars Forfurtherdetailsoftheindicators,seeKaufmannetal.(2004;2005;2006).Theindicators for are downloadable from the website; ). 8 ForfurtherdetailsoftheDALY, seemurrayandacharya(1997), WorldBank(1993), AppendixB. Theestimatesfor2002bycauseforWHOmemberstatesaredownloadable fromthe website; (accessed February, 2007). 81

14 3.3EstimationResults Theestimationresults arepresentedintable9. Column(1) presents the estimatesfromaspecificationofthepoissonregressionmodel, andcolumn(2)presents theresults for thenegativebinomial model. Bothmodels includethesameset of explanatoryvariables. Thesamplesareacross-sectional 111countriesin2003. The likelihood-ratiotestoftheover-dispersionparameteroftheneg-binmodelindicatesthe existenceofover-dispersion, suggestingthatthenegativebinomialmodelispresumedto bemoreappropriatethanthepoissonmodel for thedataset. Figure1shows the relationshipbetweenthecumulativenumber of GHPsasof 2002andthesumof 6 indicesofgovernanceindex. ItseemsthatGHPistargetedatthecountrywhichperforms lowgovernanceaslongasthisfigureisseen. GovernanceIndex Table9:EstimationResults Thedependentvariable:ThenumberofGHPs (1)Poisson (2)Neg-bin [0.014]** [0.024]* Burdenofinfectiousdiseases(1,000DALY) Healthexpenditurebypublic(%ofGDP) ln(gdp) Constant Over-dispersionparameter [0.004]** [0.014]** [0.036]* [0.059] [0.027]** [0.046]* [0.658]** [1.104]** [0.080]** Observations PseudoR-squared Loglikelihood Note:Standarderrorsinparentheses. *Statisticallysignificantatthe5%level, **atthe1% level. Over-dispersionparameteristestedbyalikelihood-ratiotest. 82

15 Figure1 thecumulativenumberofghps(202) TheRelationshipbetweenGHPsandtheGovernanceofRecipientCountry Sumof6indicesofgovernance(2002) Figure2 thecumulativenumberofghps(202) TheRelationshipbetweenGHPsandtheGovernanceWeightedbyDALY Sumof6indicesofgovernance(2002) 83

16 Infact, theestimatedcoefficientsonthegovernanceindexaresignificantand negative, contrarytoexpectationsinboththepoissonandnegativebinomialmodels. 9 In both models, the calculated marginal effect of governance on GHP entry was approximately-0.25, implyingadecreaseinfour units of thegovernance scoreis associatedwithoneghpentryintherecipientcountryonaverage, withallotherfactors heldconstant. Althoughthisresult isaninterestingfinding, it isinconsistent withthe argument ofthecmhreport, namelythat theabilityofgovernanceandmanagement shouldbenotedasafactortodeterminefinancialsupporttothecountry. Oneexplanation forthiscomplicatedresult maybethat thehugeburdenofdiseases, ratherthansuch politicalfactors, hasbeendrawingthesupportofghp, anaspectwhichispartlyrevealed intheestimationresult. Thecoefficientoftheburdenofinfectiousdiseasesisstrongly significantandpositiveasexpected, indicatingthatthegreatertheburdenofinfectious diseases, thehigherthenumberofghp. Figure2alsodemonstratethescatterplot of GHPsagainst thegovernance, but thesizeofsymbolsreflectsthedalyaggregated suggeststhatghpstargettheburdenofdiseasessignificantly. Itmaybereasonableto presumethattheseresultsarelinkedtothefactthatalmostallghpshavebeencarrying outactivitiessuitedtothepurpose. Publicexpenditureinthehealthsectorshowsanegativecorrelationwiththe numberofghpswhiletheresultofthenegativebinomialmodelrevealsinsignificance. ThisresultisacceptablebecauseitisconsideredthatGHPshelpsupportcountrieswhich haveinsufficientfundingforthehealthsector. Themarginaleffectofhealthexpenditure inthepoissonmodeliscomputedas-0.4, whichmeansaonepercentincreaseinpublic TheestimationequationalsoincludesGDPinnaturallogarithmstocontrolthesizeeffect ofthecountryinvolved, whilethegdpcoefficient isalsonegativeandsignificant in bothmodels. ThisresultsuggeststhatGHPmayenteracountry, evenifthecountryscale issmall. 9 Withoutusingthesumtotalofsixindexes,evenifitusedoneindexsuchastheindexof govermenteffectiveness, theresultdidnotchange. 84

17 4. ConcludingRemarks This paper investigates thedeployment situationof GHPindeveloping countries, puttingghpinorderfromvariousangles, suchasapproachandtargeted disease, andresearchesthenatureoforganizationsthathaveplayedmajorrolesinthe healthsector, especiallyintermsofthepartnershipparticipatingsubjectandthefund donationsubject. AremarkableincreaseinGHPwasespeciallyapparentinthesecond halfofthe1990s, peakingin2000. So-calledneglecteddiseaseswerefoundtobe coveredbyatleastoneormorepartnership/swhilemanyghpsconcentrateonthree majordiseases, suchashiv/aids, tuberculosisandmalaria, reflectingthedegreeof attentionandtheseriousnessoftheireffects. Itisindicatedthatthestanceadoptedbythe publicandprivatesectorstocopewiththesediseasesviaamarketmechanismdoesnot function. TheresultsofresearchintomajorparticipantsandfoundersofGHPindicate thatthecontributionofthegatesfoundationissignificantlyhighfromtheperspectiveof fundscaleandcoverage, whilevariousorganizationshavecooperativelyparticipatedin GHP. It shouldalsobe notedthat substantial numbers of GHPs exist solelyon contributionsfromthegatesfoundation. Further, empiricalanalysisattemptstoclearlyshowwhetherapartnershipis implementedamongrecipient countriesandwithwhat kindofattribute. Althoughthe CMHreportclaimedthatsupportbythepartnershipmustbeofferedtocountrieswhere theperformanceofleadership, accountability, andtransparencyandfundmanagement abilityishigh, thereisnothingthatanalyzedtherealityofwhathasactuallyhappened. The earlier studybycarlson(2004), meanwhile, examiningthesingle correlation coefficient betweenghpnumbersandcountrycharacteristics, concludedthat thereis moderatecorrelationbetweentheprevalencerateorcasenumberofadiseaseandthe GHPpresence, butnocorrelationbetweengovernanceandtheghppresence. Thispaper tocontrol multiplefactors simultaneously. Theempirical result reveals that GHPs areindeed implementedincountrieswheretheperformanceofgovernanceislow, contrarytothe argumentofthecmhreport andthepreviousstudy. Themodelalsotakesintoaccount theburdenofdiseasesasademandfactor, andshowsthatthereisastrongandpositive correlationbetweenthepresenceof GHPandtheburdenof diseases. Onepossible 85

18 explanationfortheseresultsisthatthetargetconditionsforghpexclusivelyconsistof countrieswheretheburdenofdiseasesishigh, evenifitincludesthosecountrieswith weakgovernance. InordertoevaluatethefinancialsupportadministeredviatheGHPto suchcountries, theresultsofthispapercoveranothercontroversialissue, namelyhow theeffectsoftheghppresenceonthehealthsectorinthecountrydiffer, basedonthe governanceindicatorsamongrecipientcountries. Furtherresearchshouldfocusonsuch issue. Whilethispaper uncoveredsomeinterestingfacts, several points must be borneinmindrelatingtothedataissue. Sinceestimationsmadeinthispaperarebased onthenumberofghpsinsteadofafundingscaleandcrosssectionaldata, theresultsdo notnecessarilyreflecttheexacteffectsandthecausalitybetweentheghppresenceand theexplanatoryfactors. Further analyses usingricher data withtimesequences is essentialinordertoovercomethisshortcoming. Moreover, toevaluatetheactivityof GHP, it will benecessarytocollect informationontheoutpu Althoughtheseissuesremainunsolvedandrequirefurther examination, it shouldbe notedthat the findings onthedeterminants of GHPprevalence contributetoward deepeningunderstandingoftheghpdeploymentsituationandimplytheimportanceof investigatingthepossibleinefficiencyofghpincountrieswithlowgovernance. References AppliedEconometrics, Vol. 1, No. 1, January: ournalof Caines, Karen;KentBuse;CindyCarlson;Rose-mariedeLoor;NelDruce;CheriGrace; ImpactofGlobalHealthPartnershi Paper4. DFIDHealthResourceCentre. HealthResourceCentre. 86

19 CommissiononMacroeconomicsandHealth InvestinginHealthforEconomic Development withanapplicationtothepatents- l. 52, No. 4, July:pp Review. 18:pp Kaufmann, Daniel, AartKraayandMassimoMastruzzi GovernanceMattersIV: GovernanceIndicatorsfor WorldBankPolicyResearchWorking PaperNo Washington, D.C. AggregateandIndividualGovernanceIndicatorsfor1996- JournalofHealthEconomics, Vol. 16, Issue6, December, pp private Partnerships for Health: Atrend with no -48. WorldBank WorldDevelopmentReport1993:InvestinginHealth. NewYork: OxfordUniversityPress. World Health Organization, Commission on Macroeconomics and Health MacroeconomicsandHealth:Investinginhealthforeconomicdevelopment. WorldHealthOrganization, International FederationofPharmaceutical Manufacturers.int/intellectualproperty/documents/en/). 87