Introduction Almost the entire cost of health care in the developing world is borne by the developing countries themselves. According to two separate estimates, aid from international health organizations in the developed countries pays for less than 5% of the total health care costs in the developing world. The estimates do not specify exactly what they include as health aid, but they probably omit the value of food relief and other health-related disaster relief, as well as money spent on water supply and sanitation projects, although these activities have important health benefits. Nor do they seem to include the work done in the home offices of international health organizations - e.g. the publication of manuals for health care workers in developing countries, the development of model health care systems, the strategic planning for campaigns against tropical diseases. Finally these estimates omit the monetary value of the following: the labor of volunteer health workers, research in tropical diseases done at medical institutions in the industrialized countries, drug development for tropical diseases by major pharmaceutical firms (e.g. the anthelminth, ivermectin, developed and manufactured by Merck & Co. at a net loss), and the development of equipment by international companies for use in poor countries (e.g. the development of low cost x-ray equipment by General Electric). Even if all these items were counted, however, the total value of the aid from abroad would still account for much less than 10% of the total health expenditures in the developing world. Nevertheless, it is important to note that, in the very poorest countries, the percentage of health care costs donated by the developed world is considerably greater than the 5% average. In sub-Saharan Africa (excluding South Africa), aid from donor countries averages 20% of total health expenditures, according to the World Bank, and for five countries - Burundi, Chad, Guinea-Bissau, Mozambique, and Tanzania - donor aid pays for more than 50% of the total health bill. Although the aid given to the developing world as a whole is relatively small in financial terms, it can be of crucial importance. Research and pilot programs sponsored by agencies from the industrial nations have generated many of the best ideas for improving health in developing countries. Also, the international health organizations are a major source of expert technical advice and training for local health professionals. Finally, these organizations produce the major textbooks in tropical health, as well as the most important manuals for health care workers. A large number of organizations of various sizes provide international health aid. The exact roles played by these organizations can be bewildering at times, even to professionals in this field. What follows is a description of the functions of the largest international health organizations. After a look at the major organizations providing long-term health care, the focus shifts to those that specialize in giving aid to victims of war, famine and natural disasters. Organizations Providing Long-term Health Care Multilateral Agencies International health organizations are usually divided into three groups: multilateral organizations, bilateral organizations, and non-governmental organizations (NGOs). The term multilateral means that funding comes from multiple governments (as well as from non-governmental sources) and is distributed to many different countries. The major multilateral organizations are all part of the United Nations. The World Health Organization (WHO) is the premier international health organization. Technically it is an "intergovernmental agency related to the United Nations." WHO and other such intergovernmental agencies are "separate, autonomous organizations which, by special agreements, work with the UN and each other through the coordinating machinery of the Economic and Social Council." According to its constitution (1948) its principal goal is "the attainment by all peoples of the highest possible level of health." WHO has three main divisions. The governing body, the World Health Assembly, meets once a year to approve the budget and decide on major matters of health policy. All the 190 or so member nations send delegations. The World Health Assembly elects 31 member nations to designate health experts for the Executive Board, which meets twice a year and serves as the liaison between the Assembly and the Secretariat, which carries on the day-to-day work of the WHO. The Secretariat has a staff of about 4,500 , with 30% of the employees at headquarters in Geneva, 30% in six regional field offices, and 40% in individual countries, either as country-wide WHO representatives or as representatives of special WHO programs. The principal work of WHO is directing and coordinating international health activities and supplying technical assistance to countries. It develops norms and standards, disseminates health information, promotes research, provides training in international health, collects and analyzes epidemiologic data, and develops systems for monitoring and evaluating health programs. The Pan American Health Organization (PAHO) serves as the regional field office for WHO in the Americas and, since it predates WHO, carries on some additional autonomous activities. WHO has a biannual budget. Assessed contributions from the member nations constitute the regular budget. In recent years voluntary ("extrabudgetary") contributions - from governments and private philanthropies - have exceeded the regular budget. Donors may earmark voluntary contributions for special programs; WHO allocates assessed contributions. For the period 1994-95 the total budget was $1,872 million, of which $628 million went to disease prevention and control programs. The largest single budget item was the program for the prevention and control of AIDS and other sexually transmitted diseases, $181 million. The program for integrated control of tropical diseases had an allocation of $118 million, and tropical disease research, $80 million. The programs with the next greatest budgetary allocations were in the area of health system infrastructure - health systems development, organization of health systems based on primary health care, development of human resources for health, and public information and education for health. WHO spent $404 million on these programs. The World Bank is the other major "intergovernmental agency related to the UN" heavily involved in international health. The World Bank loans money to poor countries on advantageous terms not available in commercial markets. The amount of money loaned to developing countries for human resources development, i.e. health and education, has increased steadily over the past 10 years, from 5% of total loans in the early 1980s to 15% in the past two years, with a projected 50% increase in human resource development loans over the next three years. The total amount of loans for health, nutrition, and population activities in 1995 was approximately $1,200 million. Three subsidiary agencies of the UN Economic and Social Council are heavily committed to international health programs. The United Nation Children's Fund (UNICEF) spends the majority of its program (non-administrative) budget on health care. UNICEF makes the world's most vulnerable children its top priority, so it devotes most of its resources to the poorest countries and to children younger than 5. In 1994 UNICEF received about $1 billion in contributions, all voluntary - 70% from governments and 30% from private sources. (The US government is the largest single donor to UNICEF, but the per capita contribution from the US, including private sources, is much less than that from Canada, Switzerland, the Netherlands, and the Scandinavian countries.) In 1994 UNICEF spent $202 million on child health, $81 million on water supply and sanitation, $30 million on child nutrition, and $216 million on emergency relief. UNICEF runs many of the child health programs in cooperation with WHO. The United Nations Population Fund (UNFPA) spent about $130 million of its $260 million budget for 1994 on family planning programs, with 59 priority countries receiving 70% of this money. (Priority is based on rate of population growth and poverty.) The United Nation Development Programme (UNDP) allocated $141 million, out of a total budget for field expenditures of $1 billion, to "health, education, employment." Its major health concerns are AIDS, maternal and child nutrition, and excessive maternal mortality. In conjunction with WHO and the World Bank it sponsors the Special Programme for Research and Training in Tropical Diseases (TDR). Bilateral Agencies Bilateral agencies are governmental agencies in a single country which provide aid to developing countries. The largest of these is the United States Agency for International Development (USAID). Most of the industrialized nations have a similar governmental agency. Political and historical reasons often determine which countries receive donations from bilateral agencies and how much they receive. For example, France concentrates on its former colonies, and Japan gives mostly to developing countries in Asia. In 1994, USAID, through its Center for Population, Health, and Nutrition, donated $1,050 million for long-term health care in developing countries. USAID channels most of this aid through "cooperating agencies" - private international health agencies which contract with USAID. Non-governmental Organizations Non-governmental organizations (NGOs), also known as private voluntary organizations (PVOs), provide approximately 20% of all external health aid to developing countries. Most of these organizations are quite small; many are church-affiliated. In the very poorest countries, hospitals and clinics run by missionary societies are especially important. Data from Uganda indicates that church mission hospitals are much more efficient than government health facilities, with mission doctors treating five times as many patients as their counterparts in government facilities and mission nurses attending twice the number of patients that government nurses do. The largest NGO devoted to international health in the United States is Project Hope, with an annual budget exceeding $100 million. Worldwide, the most important NGO in long-term international health is probably Oxfam, International. Founded in the United Kingdom in 1943, it now has affiliates in 10 other countries, including the United States. Refugee and Disaster Relief Organizations In most natural disasters, e.g. earthquakes, floods, volcanic eruptions, the majority of deaths occur in the first few hours or days, and likewise most of the lives that are saved are saved early on and saved by local efforts at disaster relief. A major disaster, however, can overwhelm the resources of a poor country and, by destruction of an already somewhat tenuous economic and social infrastructure, set the stage for famine and epidemics. The aid provided by international relief organizations in the days immediately following the disaster can play a major role in averting health crises and re-establishing a functioning society. In contrast to natural disasters, famines and refugee crises tend to develop slowly, often preceded by warning signs of the impending emergency, so that international agencies can coordinate relief efforts with national agencies in a timely fashion. The United Nations agencies are probably the most important of the international relief organizations, but there are several very large NGOs active in refugee and disaster relief. Two of these, the International Committee of the Red Cross (ICRC) and Medecins Sans Frontieres, perform special functions that will be discussed below. United Nations Organizations Six major UN organizations are involved in refugee and disaster relief. The Department of Humanitarian Affairs, established in 1992, coordinates UN activities in this area. The Department operates on a 24-hour basis the UN Disaster Assessment and Coordination Team, which can be deployed immediately to an affected country. Three of the six major agencies are mentioned above in the section on long-term health care. UNICEF allocated $216 million to emergency relief in 1994. The WHO budget does not contain a line item for disaster relief, but WHO is active in this area through its Division of Emergency and Humanitarian Action, which coordinates the response of the international relief community and supplies technical assistance and emergency drugs and equipment. UNDP allocated $59 million to disaster relief in 1994; its special function is organizing efforts at rehabilitation in the disaster-struck area. The World Food Programme (WFP) supplies food relief in disasters and coordinates the activities of NGOs involved in food relief, as well as assisting them with transportation and logistics. In 1994 it spent $874 million on relief. The WFP also supports agricultural and rural development ($181 million), and education ($131 million). The Office of the UN High Commissioner for Refugees (UNHCR) provides international protection to refugees and also attempts to find long-lasting solutions to their problems. UNHCR is the major international organization for the world's 20 million refugees. It aids refugees directly and coordinates the work of NGOs involved in refugee relief. Although it has no formal authority over displaced persons), upon request of the UN General Assembly and the Secretary General, UNHCR has provided assistance to displaced persons in such countries as Bosnia and Herzegovina, Somalia, and Rwanda in recent years. In 1994, UNHCR spent almost $1.2 billion on its programs. The sixth of the UN organizations involved in relief work is the Food and Agriculture Organization (FAO). Like the World Bank and WHO it is technically an "intergovernmental agency related to the UN." It helps developing countries prepare for famine through its Global Information and Early Warning System and its Food Security Assistance Scheme, which helps developing countries set up national food reserves. In disasters its principal role is to assist in the re-establishment of agricultural production. Bilateral Agencies As is the case with long-term health care, most of the developed countries have a governmental agency dedicated to providing disaster relief. In the United States, disaster relief is for the most part a function of USAID, which spent $1.3 billion on such aid in the three year period 1992-94. The US Armed Forces also assist in disaster relief on occasion. Non-Governmental Organizations The International Red Cross and Red Crescent Movement is the largest and most prestigious of the world's humanitarian NGOs. It has three components: the International Committee of the Red Cross (ICRC); the International Federation of Red Cross and Red Crescent Societies; the 160 or so individual national Red Cross societies, e.g. the American Red Cross. The seven fundamental principles of the Movement are: humanity; impartiality; neutrality; independence, i.e. autonomy vis-à-vis national governments; voluntary service; unity, i.e. for each country only one national Society, open to all and serving the entire country; universality. The ICRC is a Swiss organization, founded in 1863 and mandated by the Geneva Conventions to protect and assist prisoners of war and civilians in international armed conflicts. It may also offer its services in civil wars. Its functions include: visiting and treating prisoners of war and political detainees and providing them with a communication service with the outside world; setting up surgical hospitals or providing expatriate teams to work in existing hospitals; providing other types of medical assistance and relief, especially rehabilitation of war-disabled patients; development and dissemination of educational materials concerning health care of prisoners and victims of war. In regard to this last function, the book Surgery for Victims of War is especially well-known. In 1994, the ICRC expended about $530 million on these various activities. The International Federation of Red Cross and Red Crescent Societies receives its principal support from the individual national societies. Its main mission is to provide disaster relief. It works closely with the national Red Cross societies in the affected countries. In addition, it issues international appeals for emergency aid and often serves as the organizing agency for the relief efforts of smaller organizations. In 1994 it supplied almost $400 million in disaster aid. Like the Red Cross, Medecins Sans Frontieres (MSF) provides health aid to victims of war and natural disasters. Unlike the Red Cross, MSF is willing to enter war-torn areas without the permission of authorities. Another difference between the two organizations is that MSF, although its charter includes the same principles of impartiality and neutrality followed by the Red Cross, considers one of its functions to be speaking out on human rights abuses. Usually this speaking out consists of drawing attention to cases of human rights violations that MSF considers under-reported, but on occasions MSF will take a strong stand and denounce egregious violations. Such denunciation can render the humanitarian work of MSF more difficult and dangerous. Founded in 1971 in France, MSF now has six operational centers in Europe and 13 delegate offices throughout the developed world. In 1994 it spent over $300 million on its programs and sent 2,950 volunteers into the field. In addition to aiding in acute disasters, MSF also provides aid in "chronic emergencies" (e.g. Somalia, Sudan), assists in several long-term health projects, and publishes a series of field manuals/texts on disaster medicine. Founded in 1946 to provide aid to war-devastated Europe, CARE USA is best known for providing food relief in the form of "care-packages." In the 1994 budget, donated agricultural commodities and ocean freight were the largest item of revenue - $184 million out of a total of $400 million, but the activities of CARE have expanded greatly over the past 50 years. In 1994, CARE spent $117 million on emergency aid and $249 million on a variety of development projects in the fields of small business support, population, agriculture and environment ($68 million), and health and nutrition ($158 million). In disasters, CARE has special expertise in transportation of supplies and logistics. Since 1980 affiliated CARE agencies have been established in 10 countries, leading to the creation of CARE International, headquartered in Brussels. Like CARE, Catholic Relief Services (CRS) specializes in providing food relief. In 1994, one half of its $300 million in revenue was in the form of food and ocean freight. It spent $132 million on disaster relief, $85 million on development assistance, $61 million on general welfare, and $14 million on refugee relief and resettlement. CRS works closely with Caritas, the international organization of Catholic charities. This document minimizes the complexity of the world of international health organizations. We have discussed only the largest organizations and have not mentioned by name many excellent, somewhat smaller NGOs, with long records of valuable contributions to health care in developing countries. Also, we have oriented this discussion to the American reader, omitting specific mention of outstanding bilateral aid agencies and NGOs in Japan, France, the United Kingdom and other industrial nations. There are about 65 official multi-lateral and bilateral international health agencies. Several hundred American NGOs engage in international health work, and other developed countries also have their own independent NGOs. The total number of NGOs worldwide has been estimated at 1,500. Thus it is not unusual to find two hundred or more international health agencies operating in the world's poorest countries. Each of them tends to have its own prioities. Unfortunately, despite some liason committees and coordinating agencies, international meetings, and informal contacts, cooperation among these many organizations is not all it could be. For additional information we have included some links to NGOs around the world, as well as some of the best central web sites for NGO information.