The Governance of Global Health: what needs to change?

My first book review on this blog looks at a new, deep and important insight into the world of global health, how power is distributed within it, and why some issues receive lots of funding while others don’t.

I just finished reading Devi Sridhar and Chelsea Clinton’s excellent new book Governing Global Health: Who runs the world and why?. It forensically dissects the evolving role of four major global health institutions – the World Health Organization, the World Bank, the Global Fund to Fight AIDS, Tuberculosis and Malaria and GAVI, the Vaccine Alliance – in the governance and financing of public health over the past 60 years.

The governance of global health is a fundamental issue for Save the Children to grapple with, as we seek to galvanise the international community into action against pneumonia, the largest infectious cause of under five deaths. It’s a cause Devi has been one of the most vocal champions of and which she sees as a major global health challenge of our generation.

Here’s a summary of my key takeaways from this work:

1 New, vertical institutions – such as the Global Fund and GAVI – were borne out of mistrust in the more traditional institutions, including WHO and the World Bank. The perceived ineffectiveness of the UN system in dealing with the AIDS epidemic in the 80s and 90s has prompted the emergence of highly focused, results-driven organisations to channel massive chunks of the world’s aid for health. These have undoubtedly played a major role in reducing the burden of specific infectious diseases, including HIV, TB, measles and malaria (although the progress against the latter has stalled of late).

2 However, these institutions have also fundamentally reshaped the world of global health in such a way that powerful donors now exert a huge amount of influence over what the money is spent on. Part of this stems from very legitimate concerns of transparency and accountability from citizens and taxpayers – whose confidence in multilateral institutions has been eroded by multiple scandals – and an increasing drive for results across the sector. But it also comes from an increasing reluctance to delegate power to genuinely multilateral outfits. All international institutions are somewhat subject to influence from their key donors, but it’s clear that newer global health institutions have provided much more room for major donors to influence the agenda and spending decisions.

3 This enormous shift towards issue-based funding has almost certainly happened at the expense of strengthening health systems’ ability to provide comprehensive care, respond to disease outbreaks and produce a large and competent health workforce for all. We obviously cannot know whether the £60bn spent by GAVI and the Global Fund between 2000 and 2013 would have been raised and spent on more integrated work through the UN system had these two institutions not been created. But it is reasonable to assume that part of this huge pool of resources has displaced or crowded out core funding to poor countries’ health systems.

4 The world cannot respond to the global health challenges of our time – pneumonia, non-communicable diseases, climate change, the risk of global pandemics – without a much stronger, adequately funded and empowered WHO, which is the most, and probably the sole legitimate outfit for setting and enforcing global health norms. In order to achieve this, large donors – mainly rich countries’ governments and the Gates Foundation – need to learn how to do something new and uncomfortable: RELINQUISHING POWER, for the benefit of all. To get there, however, will require the World Health Organization to do two things differently:

  • achieve much greater levels of transparency on the way decisions are made
  • involve civil society organisations much more meaningfully in the decision-making process.

5 One phrase has particularly captured my attention: “a further challenge is that the conversations and debates surrounding Universal Health Coverage are rarely tied to those relating to health systems strengthening, community health-worker models, or other healthcare delivery priorities. We find this persistent decoupling illogical.” This is a challenge to all of us who are passionate about UHC to think more concretely about national pathways towards this goal – and to put effective, affordable and evidence-based approaches at the core of our discourse and advocacy at all times. One of these approaches is community case management, an equitable strategy to extend life-saving health services to those least able to visit hospitals, and to promote healthy preventive practices in villages where children are most exposed to deadly diseases. The vertical vs. horizontal debate is a distraction from the truth, which is that they are both needed and can be (should be!) mutually reinforcing.

I thoroughly recommend this book to all the governance, public health, development and health financing geeks out there. You know who you are!

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