Original Research
Financing Medical Care in Underdeveloped Nations: Reflections from the Past and Context for the Future
Jozef Van Langendonck, PhD


Abstract:
Global healthcare financing continues to create challenges for underdeveloped nations at the present time. Yet efforts to address the challenges of providing the necessary resources still continue to focus upon ad hoc solutions rather than a systemically focused, member state, mandatory contributions that build upon extant infrastructures such as WHO, WTO, the Global Fund, and other bodies. Yet it is important to realize these structures continue to need quality assurance, measurement, and evaluation, while a system of global social security oversight still needs creation that can effectively govern such efforts. A funding system based on stable funding and appropriate, governance-based structure can promote more focused, targeted financing, leading to improved global health.

Keywords: developing countries; financing healthcare; mandatory contributions; WTO; UN; WHO

Published: 10 January 2013
Cite as: Van Langendonck J. Financing Medical Care in Underdeveloped Nations: Reflections from the Past and Context for the Future
Bull Health L Policy. 2012;1(2).

Introduction

It is less than a century ago that medicine emerged as a reasonably dependable source of cure, at least a certain number of diseases and injuries of which mankind had hopelessly suffered for centuries. Until about 1920, the chances anyone would really profit from seeing a physician, i.e., the patient would suffer less rather than more, were on average less than 50%. From that time on, however, the progress in medical science and technology has been such that there can be no doubt regarding the true and essential value of medical care for sick and injured persons, and indeed for humankind in general.

Science and technology have since continued to advance at a rapid and always more accelerating pace. Previously incurable conditions can now be detected and treated with remarkable success. An increasing number of diseases can be efficiently prevented, often at a rather low—and sometimes ridiculously low—cost. Not only do people survive longer, but they survive in better health. Whatever skeptical attitude one may take towards the advance in science, there can be no longer any discussion—apart from some very particular cases—about the utility of this progress. And the technology has followed at such a pace and with such an extension, that the results of this progress are readily available everywhere on the planet, even in the most remote places.

However, equity in social security has not been balanced. There are and continue to be areas where little benefit from these medical treatment advancements reach due to their costs, contexts, and related issues. These are reviewed below, and drawing upon historical and practical notions, hopefully some lessons for future financing of care can be provided.

Nations, Health, and “Soft” Law
It was not long before the idea that medical care progress could not be limited to those who could afford it took hold in the consciousness of nations. Indeed, in the next generation, immediately after World War II, the Right to Health was officially and universally recognized as a basic human right. This was done in the American inspired.1 Universal Declaration of Human Rights of the United Nations (December 1948). Since then, it has been proclaimed in numerous other international instruments and in all modern national Constitutions.

Unfortunately, there is a tendency to take this right lightly, as being “soft law” without real binding power. The fact is all of these instruments proclaim this right – and similar basic rights – in general terms, without any further definition. It is far from clear what it actually means. What are citizens of the world entitled to under this Right to Health? It cannot be health as such. A person cannot be entitled to sue the government because he or she has become ill. Generally speaking, a government of a country having ratified the international instruments concerning the Right to Health will have a duty to provide protection against damage to their people’s health. This means, among other things, creating a system of organization and financing to make sure that all citizens have access to medical care. That is indeed what most of these governments have done, at least for the majority of their population, and as best as resources allow. But governments can hardly be taken to court for having failed to do so. The only sanction on this obligation appears to be a political one.

Certainly, for the largest part of the world population, this right has no real meaning at all. The proclamation of their Right to Health has not changed their access to sanitary conditions or to medical care in any way. And even in a number of highly industrialized countries one cannot really state that the right to health is guaranteed to all citizens. What is the problem and what can be done about it?

A Problem for All Nations

Medical care is not only a right, it is also a commodity. It consists of goods and services that must be produced in order to be consumed (and paid for). It requires investment in buildings, equipment and training, and in research and development. And its operating costs are not negligible. Medical care cannot be free.

The natural way of distributing goods and services in society is by the market mechanism. People pay according to the value these goods or services appear to have for them, and the producers sell according to what this production costs to them. In an open market this leads to an equilibrium between supply and demand at a market price. The problem is that this market price may put the goods and services beyond the reach of a segment of the population who need them most. This concept is less important for consumer luxury items and durables, but it matters a great deal when this is about essential healthcare goods and services, to which people are entitled by “right.”

Historic Context
Global society has come up with various remedies for this. The first one has been charity. The wealthier in society have given to the poor, individually or collectively, often through institutions or foundations catering for the needy. The poor, instead of being grateful, have always resented this and looked for ways to provide for their own, without being dependent on charity or assistance. They have since time immemorial constituted little self-help groups, later developing into mutual aid societies at a more or less large scale. Medical practitioners have also created their own prepaid schemes guaranteeing care for their members for a weekly fee. But all of these voluntary efforts could only bring access to care to those who had the foresight to join and who had the means to pay the fees.

It is only when health insurance became compulsory – for the first time, improbably, under the Prussian chancellor Prinz Otto von Bismarck in Germany in the 1880s – that the right to medical care could be extended to whole groups of the population. This “Bismarckian” social insurance has proved to be extremely popular. It was immediately exported to the neighboring countries in Europe, and it has gradually conquered practically the entire globe. Today, one finds merely a handful of countries without at least some form of compulsory social health insurance.

The Issue of Cost
Particularly from the 1950’s on, the cost of medical care has become a significant problem, even in the most industrialized countries. Until that time one could expect2 - and experts actually expected - that total expenditures on medical care would remain more or less constant, at least in relative terms, compared to national income. It was clear even at that time that medical services and drugs were becoming more expensive as they became more sophisticated, but it was expected the wider access to care would improve the health situation of the people so that they would have less need of calling upon the healthcare system.

As we know now, the opposite has happened. The paradox of medicine is that it keeps more people alive. Persons in poor health are kept alive much longer needing constant medical attention. And more people reach old age in which they need more medical care.

This result cannot be a bad thing in itself. In societies that become ever more wealthy, it is better that the extra revenue is spent on healthcare, rather than on games, drugs, or even harmful activities. Still, in medical care - and not, for example, in informatics - this is perceived as a real problem in the rich nations, where medical economics has become an important specialization in economics, and where governments have tried wave upon wave of reforms trying to stop the “healthcare costs explosion”. These efforts are of little or no avail, and often are doing more harm than good.
Healthcare and the Market
The fact is that the demand for medical care is very strong and is not easily influenced by economic measures. The market mechanism appears not to work in the normal way when it comes to healthcare. Normally demand should go down when the price goes up, but the demand for medical services and drugs is practically insensitive to changes in price, i.e., it appears inelastic. Indeed, sometimes it would appear that people are more strongly attracted to services or products for which they have to pay much more (the Giffen Good3). Due to limited or lack of any information about quality or efficacy, consumers tend to take price as the best indicator. It is not easy to see how, under such conditions, one can come to a more economical provision of medical services.

Problem Psychology
The real problem is not that of the cost as such. It is that medical care deals in large part with irrational decisions due to the potential negative end nature (e.g., suffering; death). For human beings, these are very difficult matters to cope with. When faced with such realities, humans tend to turn towards religion, superstition, even witchcraft, in the hope that somehow they will be cured.

The physician very often takes his or her place in this type of cultural system and environment. His or her patients will require this or that type of cure, given by this or that person, because they have heard somewhere that this would be most efficient/effective. And physicans tend to give in to this type of demand, despite higher costs and poorer outcomes.4

Physicians also have a fear factor in their practice. There is the economic fear of not doing well in their practice. They need not only to treat and cure their patients, but also to keep them as patients. To a certain extent this means satisfying their demands, even if they are not really justified or even rational. And increasingly, in the most industrialized countries, there is the fear of malpractice suits from their clients. This is already a widespread phenomenon in the U.S. and it is trending to extend to other countries in the future. All of this makes it difficult to apply clear scientific standards in the financing of medical care, as the experience in reality shows.

The Real Problem: Consumer or Health Oriented System?
The real choice to be made in healthcare financing and management is between a consumer oriented or a health oriented scheme. The first type of scheme allows for the irrational element in healthcare. It tends to give the consumer what he or she wants, whether it is scientifically justified or not. It considers that the anxiety of the patient is an important fact in itself, and addressing it is in itself an important objective of the scheme. It puts free choice of the consumer as its most important principle. The American healthcare system can be seen as the model of this conception.

The second type of scheme emphasizes the use of organized medicine. It is recognised that consumers lack sufficient scientific and factual information to find the best care. People cannot have total free choice of provider. They receive their care through a rational and scientifically justified system. The British National Health Service is considered the model for this type of scheme.

Yet in the first type of scheme, consumer satisfaction will be very high, but expenditures will also be very high, and the results in terms of health statistics may not be brilliant. So it is in the U.S., where medical care takes 17.6% of GDP, while the country has only a modest rank in the world health statistics. The contrary is true for the British National Health Service, which for a cost of around 9.6% of GDP,5 is among the best in the world in terms of health statistics (after the Netherlands and the Scandinavian countries). But the British Government faces a constant stream of complaints and criticism from consumers.

Of course, these are not pure models. All schemes in the world, including these of the U.S. and Britain appear as a mixture, with elements of both types in them. However, the real choice to be made is between rational results in terms of health outcomes, or satisfaction of the consumers, regardless of cost. And of course, this is not a real choice. One wants to give both a rational scheme
and freedom of choice. In the real world this is possible only when one caters for a limited population where sufficient funding is not a problem. But in most systems the problem is to find the right balance between both elements.

Healthcare Needs Exacerbated in Underdeveloped Nations
The problem of financing and organizing medical care is, of course, much more difficult in underdeveloped countries, where large portions of the population live below the poverty line and where governments lack the essential tax base to fund the most basic of their public duties. The 2012 World Health statistics report of the Global Health Observatory of the WHO (figures for 2009) shows that at least 38 countries have less than $44 to spend on healthcare per year, as compared to $8262 in Luxemburg, whereas its High Level Task Force on Innovative International Financing for Health Systems estimated that at least that amount is needed to provide essential services with respect to the worst threats to health.6 As a result of this, the report estimates that in these countries, one person out of ten suffers every year catastrophic poverty because of ill health. The above figure refers to spending from all sources, including out-of-pocket payments.

It is clear that in those countries both the population and the public authorities simply do not have sufficient resources to pay for modern medicine at even a minimal scale. This fact has been expressed in an effort to put an end to this scandalous situation. In the hopeful year 2000, all 191 member States of the UN and a number of competent international organizations agreed to the so-called “Millennium Goals”, to be achieved by 2015 – which at that time appeared safely far away. At least three of these goals refer to essential healthcare: reducing child mortality, improving maternal health and combating AIDS, malaria and other communicative diseases. Some progress is being reported, but in 2009 still 8.1 million children under the age of 5 died, mainly of diarrhea and pneumonia, 350,000 women died because of pregnancy or childbirth, and still an estimated 1 billion people suffered – and probably still suffer - from neglected tropical diseases.

Potential Solutions
All of this is well known. Some progress is being achieved but the health situation in underdeveloped countries is still scandalously poor. So what can be done? One can distinguish three lines of solution.
International aid

If there is not enough money in the country, it has to be brought in from outside. This is indeed happening. Considerable amounts of funds are transferred year after year from the industrialized world to the developing countries by way of development aid and international assistance, both at the governmental and at the non-governmental level. According to OECD statistics, the official development aid to developing countries amounted in 2010 to more than $130 billion. A large part of this assistance, about 39%, is directed at social programs, among which healthcare takes a prominent position. In some of the poorest countries this foreign aid represents 80% or more of the budget of the Ministry of Health. Without these transfers of funds, large numbers of people in these countries would not be able to receive the treatment they need. From a humanitarian point of view this is an extremely important fact.

Of course, such international assistance is not a good solution
per se. Assistance, by its very nature, suffers always from a number of inherent defects. It is precarious and unreliable. It depends on the perception of need by other countries, not in the country itself. It is determined in its size and shape by the giver, not by the recipient. It is often ill adapted to the real local needs, and its distribution does not always succeed in bringing it to those who need it most. Foreign assistance is also criticized for disturbing the local economy and for feeding corruption. Products and services given for free do not go together well with a market economy. And, maybe more importantly, it creates a situation of dependence between giver and receiver. Not without reason is such assistance often associated with neo-colonialism.

Also, alas, assistance is essentially temporary and it is not meant to go on forever. Financial assistance is usually accompanied by technical assistance, in the hope that the receiving country will after some time be capable of providing for itself. This is the official position of the World Bank and of other international institutions, such as the IMF (International Monetary Fund).

In reality, international aid is often made conditional upon the commitment of the receiving country to increase its own spending on health. But often this is not possible. In reality, international aid is usually used as a substitute for a country’s own budget allocations, a process that is called “crowding out”.7 It tends to defeat the purpose of the whole process and to undermine the willingness of donor countries to continue spending. And at the same time, the lack of medical care makes that the productive forces of the countries remain very weak, so that they are unable to improve their economic situation. Corruption takes its toll on health.8

But above all there is the point of principle: assistance, be it international or national, official or private, is contrary to human dignity. One should not receive as charity or as assistance what is due as a right.

Many experts nowadays advocate a different approach. They want international organizations to promote indigenous forms of solidarity. This should be a better way to solve social problems in these countries, rather than importing Western structures that are foreign to the native culture.

Such structures do in fact exist all over the world. They are of various types: simple savings clubs, mutual assistance societies, cooperative insurance formulas, micro credit in various forms, etc. They can do a much good in many respects. But they can hardly be counted upon to provide medical care to a whole population. They are rarely large and stable enough to finance physicians’ services and pharmaceuticals. To put it bluntly: with micro-credit one cannot build a hospital.

Also in the Western European countries the modern social security systems have their roots in old established voluntary solidarity structures, dating back to the Middle Ages. In France, Italy, Spain and Belgium they are known under the name of “Mutualité”.9 Their name designs friendly societies of mutual assistance, which were widespread among the population, particularly among farmers and working class.

It should be stressed that these venerable structures, which still enjoy a wide popularity, have not been able to bring any sort of solution to the problem of healthcare until the end of the 19
th century, when governments started subsidizing them. The model country in this respect appears to be Rwanda, where about 85% of the population is covered by such “mutuelles”, mainly because they are subsidized by the Global Fund to Fight AIDS, Malaria and Tuberculosis.10 Even with this external funding, they are too small and vulnerable to absorb the rise of medical care costs. The annual contribution of about $2 is felt to be heavy for some families, and the “mutuelle” does not really cover the cost of care, it only reduces it. In other countries they cover only a small part of the population, and certainly not those who need it most.

Compulsory social financing
These old solidarity structures have become part of a real solution only at the time when they were integrated into a system of compulsory social insurance. This happened, as one knows, first under Bismarck in Germany in 1882, to be imitated soon in most European countries.

But under any type of private or voluntary scheme, one always finds the problem of risk selection. The worst risks cannot be covered, yet it is these patients with these risks who need the protection most. It is only with compulsory social insurance that the problem of risk selection could and can be solved. The bad risks can only find protection in a large scheme, where compulsory membership forces the good risks to share with the bad risks within the same scheme. It is not until such policy can be pursued that in developing countries the problem of social protection for healthcare (and for other matters) can be addressed. But this solution is not an easy one. It requires the force of law to compel all to share in the same scheme and to pay the necessary contributions. And it needs a sufficient tax base to raise the funds to provide access to serious medical care to the whole population.11

It will be some time before all developing nations in the world will have the capability to realize this. Most of them actually have acted in this direction already. But their schemes cover only very small portions of the population: between 2 and 5%.12 These are in essence government employees and personnel of large (foreign) companies. The schemes simply do not have the financial and technical means or the human resources to cover the entire population, or even a sizeable part of it.

To make progress in solving these deep global health concerns relating to social insurance, several practical strategies can be explored.



    All of this poses a very serious problem. Developing nations find themselves unable to provide medical care to their populations, as they should. One may consider that development starts with certain centers, around the first industrialized production, and that it trickles gradually down to the rural areas, where people live their lives in the traditional way. It is true that the people in these villages do not necessarily consider themselves poor, even if the World Bank classifies them as such. But things are different when they are ill or injured. They are at risk of dying or of living forever as invalids, because they have no access to the medical care that exists and that could save them. In that sense they are certainly poor, and this condition is unacceptable.

    As far as economic development is concerned, the incidence of disease has extremely negative impact.13 Where life expectancy is very low and a large part of the active population is ill, it is very difficult to make progress in the production of wealth. This is a vicious circle in more than one way. The physicians and paramedics, whose training has mobilized a considerable part of the meager resources in the country, tend to migrate towards the industrialized nations, where they can find better conditions for exercising their profession. This medical brain drain is another setback for the economic development of their country.14

    This constitutes a serious problem also for the industrialized world. Not only do these nations need to find markets for their products elsewhere in the world, they are also faced with serious threats from the immense and increasing contrast between North and South and the reality that disease does not respect geopolitical borders. It provides the justification or at least the inspiration for certain violent conflicts and acts of “terrorism”. It feeds the streams of illegal migration that disrupts the social fabric and causes extreme xenophobic reactions. And it also brings a steady trickle of contagious diseases, which had been previously been overcome in these countries. It is clearly in the interest of the wealthy nations to take part in the effort to provide sufficient medical care to the populations in the developing world.

    A governance organization
    All of this may sound completely utopian, yet the model for such an organization does exist. In 2002 the United Nations created the Global Fund to fight AIDS, Malaria and TB. The structure and the way of operation of this fund could be used as a basis for a governance structure. One could actually use this fund for this purpose. One would have to extend the scope of its activities to all forms of medical care, not only the three particular diseases it targets now. And contributions to the fund should be made compulsory for all member countries of the UN.

    It could, of course, also be done in other ways. This task could be entrusted to the World Health Organization, the UN agency for healthcare. Or it could be given to the World Bank, since it is a financing matter for purposes of social and economic development.15 Or one could create a special agency for this purpose that has expertise in both health and development. However, the most important issue is: how to make it compulsory?

    Many formulas could be worked out to distribute the cost of this operation over the participating countries. Many such formulas are already in operation, to fund international organizations such as the UN and its various subsidiaries, such as the WHO. A specific formula could be that of the International Development Association of the World Bank. The important point is that countries should contribute according to ability to pay.

    Receiving countries should also contribute. This is a normal feature of social insurance schemes. The beneficiaries pay their contributions as insurance premiums. Entitlement to benefits is the counterpart of the payment of contributions. One should consider in particular that not everyone in poor countries is poor. The wealthy in these countries should pay their share of the medical care for the indigent.

    These contributions could be modest in size. It has been calculated that a contribution of 0.1% of GDP of all countries would be sufficient to bring the health expenditure of the poorest nations up to the minimum standard of $44 per person per year.16

    The weakness of international law is, of course, its lack of enforcement. There are some international courts, but there is no international police force to bring perpetrators before the court and they do not have power to carry out their decisions. So how could one make payment of contributions to an international healthcare fund compulsory?

    There is one possible solution. One could use the World Trade Organization (WTO).17 This organization has, admittedly, no social objective. It simply is meant to promote free trade among all nations of the world. In so doing it is often accused of a liberalistic and even anti-social policy. Free trade creates strong international fiscal competition, since governments try to reduce as much as possible taxes and other burdens on their enterprises in order to improve their competitive position. In social policy terms this is often called a “race to the bottom”. Is this organization going to bring international funding for healthcare to the developing countries?

    The strange thing is that, yes, it could do it. First of all, the organization has the power to impose decisions on its members. Theoretically, it does not have more power than the UN or than other international agencies. But in reality, the importance of access to international trade is so great that member countries have an overwhelming interest in membership of this organization. In practice, it has been shown that member countries, in order to preserve the privileges of membership, are prepared to accept decisions of the organizations, including sanctions imposed upon them. This is the only international organization that has such power to implement its own decisions.

    But can this power be used for social purposes? Yes, it can. In fact the charter of the organization provides for exceptions to the rule of free trade “necessary to protect human, animal or plant life or health” (Article XX(b) of the General Agreement on Tariffs and Trade of 1994, annex to the WTO Treaty). More generally, the organization could rightly consider, once an international healthcare fund is established, that failure to pay contributions to that fund would constitute “social dumping”, which clearly amounts to unfair competition. The organization has already used the health clause in at least two of its judicial decisions. In the case of the EU vs. the U.S. on the use of hormones in beef, it decided that the EU had not brought sufficient proof that these hormones posed a threat to the health of the beef or of the consumers. In the case of Canada vs. France on import limitations for asbestos, it decided that France was right in banning asbestos, considering the danger for the health of the population. In the future, WTO may take more decisions based on health or on social dumping considerations. In this way it would make it clear that paying a nation’s share in the social protection of workers and of the population in general is a moral obligation for those who want to reap the profits of international free trade. In the future it may become a clear legal obligation.

    The primary aim of the scheme must be to bring basic medical care to all the people of the world, even those in the poorest and most remote areas. This is, of course, in the first place the responsibility of the health authorities of each country. The international community does not have authority to act on their territory in their place. The scheme must be designed to support the local authorities in providing this service.

    The existing structures of the Global Fund may serve as a model. They are not perfect, but at least they have already been tested in practice and been improved by experience. The scheme should conclude agreements with the local authorities on the calculation of its funding, and on the delivery of benefits to the population. It would not pay blindly, but it should monitor the quantity and quality of the benefits provided. As in the Global Fund, the civil society in the countries concerned should be encouraged to submit its own proposals for meeting the needs of the population.

    A very important point would be to provide adequate payment and equipment to health professionals, to encourage them to stay in their country instead of migrating to the industrialized world. One could think of special agreements by which countries would accept that certain categories of their health professionals and some of their medical equipment would temporarily be paid directly from the fund, thus providing a stable and reliable environment in which to practice.

    The benefits should also be closely targeted to the real needs. The fund should not provide blanket payments to national social health insurance schemes catering for a relative privileged category of workers. The disbursements from the fund should be directed at financing new benefits to populations not yet sufficiently served by their national scheme.

    Conclusion
    All of this could be called unrealistic and utopian. But one should remember that the present-day social health insurance schemes and national health services, and indeed the whole of the existing social security schemes were undoubtedly called unrealistic and utopian when they were first proposed. Today they do exist. Many countries devote very large parts of their national income to them. They provide an invaluable service to their populations. Sooner or later this must become a reality also for those who are now deprived of this protection, to which they are morally and legally entitled.

    In a civilized world nobody should suffer if he or she can be cured, and nobody should die if he or she can be saved. Civilization is measured by how the fortunate in the rich parts of the world support those who suffer. If they give only on a temporary and arbitrary basis by way of charity, that is something. But real civilization begins where they agree to set up permanent structures in the way of social security, to provide a reliable form of support to those who need it. This is already being done to some extent within the industrialized countries. The world still waits for such structure to emerge at the global level, where it is most needed.


    Author(s)
    Jef Van Langendonck is Director and Professor of Law (Emeritus), Katholieke Universiteit Leuven.

    Correspondence:
    Professor Jef Van Langendonck
    Email: Jozef.VanLangendonck@law.kuleuven.be

    References (Blue Book)

    1. See “Birth of a Right” in: J. Van Langendonck (ed.), The Right to Social Security 3ff (2007).
    2. An official French expert committee estimated in 1950 that the cost of medical care would remain stable over the next 30 years.
    See C. Michel, La Cosommation medicale des Français, Nr. 3584, La Documentation Française (1969).
    3. Alfred Marshall. 
    Principles of Economics Bk.III, Ch.VI in paragraph III.VI.17 (1895).
    4. J. J. Fenton, A. F. Jerant, K.D. Bertakis, P. Franks P,
    The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. 172 Arch. Intern. Med. 405 (2012).
    5. OECD Health Statistics (2010).
    6. World Health Organization, World Health Statistics 2012
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    8. Tim Mackey & Bryan A. Liang,
    Combating Healthcare Corruption and Fraud with Improved Global Health Governance, 12(23) BMC Int’l Health & Hum. Rights (2012).
    9. There still exists an international organization of these funds, called by the French name “Association Internationale de la Mutualité” to illustrate the Latin origin of this structure.
    10.
    Health Financing: Special Issue, 11 Bull. World Health Org. 817-908 (2008).
    11. Guy Carrin & Chris James,
    Social Health Insurance: Key Factors affecting the Transition to Universal Coverage, 58(1) Intl Social Sec. Rev. 1 (2005).
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    L’Assurance Maladie en Afrique Francophone, Nutrition and Population Series, No. 37149 (2006).
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    Rebalancing brain drain: Exploring resource reallocation to address health worker migration and promote global health, Health Policy (2012) doi.org/10.1016/j.healthpol.2012.04.006, forthcoming.
    15. Tim Mackey & Bryan A. Liang,
    A United Nations Global Health Panel for Global Health Governance, 76 Social Science & Medicine 12-15 (2013).
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    A Response to Comments on “A United Nations Global Health Panel for Global Health Governance,” 76 Social Science & Medicine 24-27 (2013).

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