Student Voices 2: Assessing Proposals for Global Health Governance Reform

Student VoiceS 2Assessing Proposals for Global Health Governance Reform

Student Voices 2: Assessing Proposals for Global Health Governance Reform

March 2011

ISBN 978-1-894088-27-5

Suggested citation for the report

Hoffman SJ, editor. Student Voices 2: Assessing Proposals for Global Health Governance Reform. Hamilton, Canada: McMaster Health Forum; 2011. Available at www.mcmasterhealthforum.org.

Suggested citation for a chapter

Nicolle J, Tye M. Chapter 1: Health 8 (H8). In: Hoffman SJ, editor. Student Voices 2: Assessing Proposals for Global Health Governance Reform. Hamilton, Canada: McMaster Health Forum; 2011. Available at www.mcmasterhealthforum.org.

© McMaster Health Forum 2011

Contents of this publication may be reproduced in whole or in part provided the intended use is for non-commercial purposes and full acknowledgement is given to the authors and to the McMaster Health Forum as publisher. All reasonable precautions have been taken to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the McMaster Health Forum be liable for damages arising from its use.

Funding for this publication was provided by McMaster University’s Bachelor of Health Sciences (Honours) Program. The views expressed here do not necessarily represent the views of McMaster University or the McMaster Health Forum.

Cover photo by Steven J Hoffman, McMaster University, Hamilton, Canada.

About the McMaster Health Forum

For concerned citizens and influential thinkers and doers, the McMaster Health Forum strives to be a world-leading hub for improving health outcomes through collective problem solving. Operating at the regional/provincial level and at national levels, the Forum harnesses information, convenes stakeholders, and prepares action-oriented leaders to meet pressing health issues creatively. The Forum acts as an agent of change by empowering stakeholders to set agendas, take well-considered actions, and communicate the rationale for actions effectively.

Global Health Governance Reform >> 3

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ntable of contents

104 networked Governance Harkiran Kalkat & Samantha Buttemer

116 Global Action networks Shruti Javali

128 Framework convention on Global Health Jennifer Edge & Cheryl Liu

144 Global Plan for Justice Katherine Georgious

156 issue-Specific Global Health Laws Olivia Lee & Raman Kumar

168 Health impact Fund Tinya Lin

4 introduction Steven J. Hoffman

10 Health 8 (H8) Jennifer Nicolle & Madeleine Tye

24 committee c of the World Health Assembly Shohinee Sarma

36 international Health Partnership (iHP+) Katryna Stemmler & Carolyn Travers

52 Group of 8 (G8) Narmeen Haider & Hun-Je Park

68 Global Health Fund Lauren Daley

80 Biosecurity concert Hugh Guan

92 Global development organization Rubeeta Gill

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4 << Introduction

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nintroductionAs time passes, the global health community is increasingly experiencing fragmentation with its ever-expanding cast of players, divergent interests and conflicting agendas. Calls for reform have recently grown louder to change the way that global health efforts are coordinated, financed and prioritized. These calls recognize that global health is not being governed as effectively as possible and that innovative solutions are necessary to achieve the health-related Millennium Development Goals, global health security, and other priorities of the international community.

New ideas are floated every day for better ways to make global health decisions and allocate limited global health resources. Some proposals call for total transformation while others suggest small changes. Some rely on existing institutions while others propose new organizations. Some seek to solve all the problems facing the global health community at once while still others focus narrowly on one or two particular challenges.

Given the importance of global health governance, all proposals are worthy of consideration, but none deserve implementation without such consideration. Indeed, most would agree that future reforms, like all important decisions, must be informed by the best available research evidence and most creative insights. Yet such research and analysis that considers a broad range of proposed global health governance reforms has never, until now, been undertaken.

This edited volume offers evidence-based assessments of thirteen existing proposals for global health governance reform. These include proposals that call for the creation of or a larger role for the:

1. Health 8 (H8) 2. committee c of the World Health Assembly 3. international Health Partnership and Related initiatives (iHP+) 4. Group of 8 (G8) 5. Global Fund for Health 6. Biosecurity concert 7. World development organization 8. networked Governance 9. Global Action networks 10. Framework convention on Global Health 11. Global Plan for Justice 12. issue-Specific Global Health Laws 13. Health impact Fund

Each chapter relies on an extensive review of the available research evidence and a broad range of insights to: (a) summarize the key elements of each proposed global health governance reform; (b) identify the needs it seeks to address; (c) examine the extent to which it could strengthen global health governance and ameliorate known weaknesses in its existing architecture; (d) analyze the proposal’s political attractiveness; (e) raise implementation considerations such as costs, risks, possible harms, feasibility and equity; and (f) offer recommendations on whether the proposal should be further explored for possible implementation.

6 << Introduction

A common analytical framework was developed and utilized to help structure each chapter and ensure a comprehensive approach to each assessment. For example, when examining the extent to which each proposal may address the various challenges facing global health governance, the authors used Gostin and Mok’s six “grand challenges in global health governance” as their evaluation criteria for assessing the merit of each proposal. The use of a common analytical framework also offered the added benefit of enhancing comparability across the examined proposals (see Tables 1-3).

The authors of this report are all students at McMaster University who prepared these essays for the fourth-year undergraduate Law & Disorder in Global Health (HTH SCI 4LD3) course, offered from September to December 2010 by the Bachelor of Health Sciences (Honours) Program in collaboration with the McMaster Health Forum. In publishing this report, it is our belief that today’s students have an important role to play in global health decision-making for both their innovative ideas and future leadership of the global health community. Through this publication, it is hoped that these students can help shape the future of global health governance reform while preparing themselves to confront tomorrow’s greatest challenges.

Steven J. Hoffman

Adjunct Faculty, McMaster Health ForumAssistant Professor, Department of Clinical Epidemiology & BiostatisticsMcMaster University, Hamilton, Canada

March 30, 2011

Grandfather and granddaughter

surrounded by karst peaks and the Li

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Steven J. Hoffman, 2009.


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noverview inputs outputs intended outcomes AssumptionsShort-term Long-term

Health 8 (H8)

• Collaboration of eight influential global health players for governance

• Member expertise • Human and financial resources

• Common agenda • Joint priorities • Publications

• Establish governance role

• Improve coordina-tion of field

• Strengthen health systems

• Help meet MDGs • Leadership

• Member compliance

• Power balance • Can gain influence

committee c of the World Health Assembly

• WHO negotiations to include civil society in decisions

• Positive diplomacy between actors

• Diverse proposals

• Decisions by various players

• Better coordination

• Alignment of goals • Better collaboration and leadership

• Reduced fragmentation

• Donor and recipients accountable

• Donors do not have priority

• Civil society has equal voice

international Health Partnership (iHP+)

• Agreement to coordinate funds via existing systems

• No new funds • Donors fund national health plans

• Government implements national health plans

• Funds from donors support national health plans

• Improve long-term financing commitments

• Donors and partners will adhere to commitments

Group of 8(G8)

• Leading econo-mies increase governing authority in global health

• Greater financial and resource commitment

• Health-focused summits

• New programs

• Immediate response to issues

• Prioritizing of global issues

• Leadership in global health

• Improved health systems

• Multi-stakeholder approach

• Financial compliance

Global Health Fund • Expand existing Global Fund to address all health MDGs

• $12 billion USD per year

• Donor / recipient compliance

• Better access to health care

• Needs of state better addressed

• Increased funding based on country needs, not disease

• Self-sustaining health systems

• Prolonged commitment from donors

• New funding strategies

Biosecurity concert

• UN Security Council commit-tee coordinating biosecurity initiatives

• Activities of the Security Council

• Existing initiatives

• Forum for dialogue

• Best practices • New initiatives

• Formation of regional biosecurity networks

• Interlinked global biosecurity regime

• Countries will work together

• Countries will follow suggestions

Global development organization

• New organization devoted to human development

• Funding • Research • Government partnerships

• Knowledge and program delivery

• Coordination • Increased accountability

• Development research

• Partnerships for development

• Collaboration among all players

• Achievement of MDGs

• Granted sufficient political power and funding to operate

networked Governance

• Networks as non-hierarchal governance in global health

• Administration • Time needed to develop network

• Opportunities to collaborate

• Networks of communication

• Conferences • Partnerships

• Inter-related networks of varying sizes tackling varying problems

• Dynamic networks with permanent normal operations

• Willingness of actors to participate in networks

Global Action networks

• Issue-specific, multi-stakeholder networks

• Research • Money and time to restructure governance system

• Greater clarity on outcomes

• Collaboration among all key players

• Unifying all stakeholders involved in a given issue

• New GANs

• Web of networks working in tandem across all sectors

• Stakeholders and governments willing to collaborate

Framework convention on Global Health

• Coordinated legal framework for health systems strengthening

• Steady monetary and human resources

• Interventions for basic needs

• Priority-setting activities

• Countries agree and buy-in to idea

• Framework established

• Stronger health systems to meet basic survival needs

• Long-term commitment by key players

• Sufficient resources

Global Plan for Justice

• WHO-led compact to promote global health

• Ratification by World Health Assembly

• Funding by states’ GNI

• Grants to accomplish major goals

• Access to essential medicines

• Access to basic survival needs

• Strengthened health systems

• Sustainable agricultural practices

• Nations will voluntarily fund plan

• Will not be economically detrimental

issue-Specific Global Health Laws

• Governance based on targeted, specific health treaties among states and key non-state actors

• States give financial resourc-es to finance laws based on ability

• Targeted global health legislation

• Support by the WHO

• Establishing the WHO as the platform for treaty negotiations

• Incremental but effective, specific global health laws

• WHO has enforcement powers

• Laws have universal support

Health impact Fund

• Fund to incentivize R&D by rewarding impact of new drugs

• $6 billion USD per year

• Administrative body

• Drugs sold at low cost

• New drugs for poor

• Health impact data

• New drug innovations

• Affordable drugs • Health impact data

• Global disease burden alleviation

• Other less expensive alternative options not as effective

table 1: Key elements of the thirteen Proposals for Global Health Governance Reform

8 << Introduction

Global Health Leadership

Harnessing creativity, energy and Resources

coordination among Key Players

Basic Survival needs and Health Systems

Funding and Priority-Setting

Accountability, transparency, Monitoring & evaluation

Health 8 (H8)

• Gain visibility, capitalize on members’ strengths

• Diverse ideas, institutional, financial, research resources

• Coordination and collaboration are central tenants of model

• Both established as areas of primary concern

• Could promote prioritization, funding presents challenges

• Greater trans-parency and evaluation tools necessary


• Form superstructure that puts WHO at centre

• Assemble various players represent-ing governance, financing and delivery

• Employ polylateral diplomacy for consensus-building

• Limit competition between local government & international NGOs

• Civil society gives direct input to donors on funding priorities

• Increase in accountability from donors to recipients & vice versa


• Establishes control but fails to set an agenda for world health improvement

• Engages non-state actors, but does not offer incentives to encourage adherence

• Attempts to align donors, but needs to work through existing plans and procedures

• Aims to strengthen health systems but lacks information and evidence

• Tries to move away from vertical aid towards sustainable systemic aid

• Little attention paid to these factors meaning there is minimal evidence of advancement

Group of 8(G8)

• Stronger leadership from politically and financially power-ful member states

• Greatest source of financial resources in global aid

• Bring together health ministers and organizations to coordinate action

• Shift in focus from disease-specific programs to health systems strengthening

• Health-focused summits to prioritize issues and catalyze compliance

• Ministerial re-commitment leading to “ratchet effect”

Global Health Fund • Would increase the leadership role and autonomy of recipient countries

• Must capitalize on existing, innovative funding mechanisms

• A shift from vertical funding could enhance coordination and collaboration

• Both disease spe-cific funding and health systems strengthening are necessary

• Financial resources to fund this proposal are presently unavailable

• Current self- evaluation prac-tices of the Global Fund would remain

Biosecurity concert

• Leadership provided by the UN Security Council

• Unclear if parties other than states can be harnessed

• Achievable through common dialogue space

• Basic survival needs may be forgotten

• Uncertain as it is dependent on individual initiatives

• Doubtful unless monitoring and enforcement measures are established


• Might be met by criticism and scrutiny by those in favour of the WHO’s leadership

• Large and suc-cessful role in gen-erating research, knowledge, and creativity

• Part of expected functions but seems unlikely to be successful

• Could be successful while contributing towards MDG achievement

• Might not be effective, as there is no mechanism to ensure compliance

• Could make other organizations more accountable for their actions


• Leadership divided among actors in separate networks

• Allows for the involvement of varying actors, maximizing resource use

• Networks provide communication link, facilitating coordination

• Not applicable • Actors fund and prioritize initiatives associated with their networks

• WHO could take primary adminis-trative role, maintaining transparency


• Unifies actors in specific areas of global health

• Participation and solutions from multiple stakeholders on specified issues

• Could serve as coordination mechanism for actors involved in particular areas

• Could develop a GAN to concentrate efforts and resources on this issue

• Could be used as mechanism to attract funding or set priorities

• GANs could undertake accountability, monitoring and evaluation activities


• Creates focal point for multiple stakeholders in global health

• Engages national governments, private sector, and civil society

• Negotiable guiding principles and Conference of the Parties created

• Aims to provide basic survival needs for health systems strengthening

• Pinpoints areas of cost-effectiveness and uses proportion of GNP to raise funding

• Coordinator sets standards, monitors prog-ress, and medi-ates disputes


• Will aide in re-establishing WHO as leader in global health

• Can harness the energy and resources of public, but not private actors

• May not effectively coordinate with non-health actors

• Addressing this need is one of the mandates of the GPJ

• Being a WHO-led program may enable effective funding and priority setting

• Can ensure accountability, but may overburden recipient states


• WHO would serve as global health leader and platform for negotiations

• Can mobilize resources and creativity from many participants

• Would bolster WHO’s role as coordinator of many players

• Does not comprehensively address systemic issues

• Priorities are skewed due to focus on consensus and voluntary nature

• Could include mandatory impact evaluations

Health impact Fund

• Will not take up leadership or coordination of players, but will be affected by lack thereof

• Incentivize research, development and distribution of essential drugs

• Administration will increase coordination for market clearance and sublicensing

• Focuses on development and distribution of medicines, not rest of health system

• Funds drugs based on health impact, but will need enduring funding

• Monitoring and evaluation of fund concept is planned

table 2: How the thirteen Proposed Reforms Address Six Grand challenges in Global Health Governance


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nKey Players tasks costs Risks opposition Possible HarmsHealth 8 (H8)

• Health-related UN agencies

• Leading funders • PPPs

• Bi-annual forum • Align agendas • Consensus • Compliance

• Coordination costs

• Inexpensive

• Not accepted as leader

• Lack of compliance

• Civil society • Private actors • Excluded important actors

• Sever ties within H8

• Further diversion of resources & agendas


• Executive Board • Member states • Donors and civil society

• Harness political will, draft WHO resolution

• Part of WHA costs • Actors pay to attend

• Smaller groups may not attend due to travel costs

• Member states may oppose to protect sovereignty in decisions

• Actors with political and economic influence may bias decisions


• Signatories of Compact

• Governments • Development agencies

• Establish monitor-ing systems

• Accountability incentives

• Communication

• Minimal cost • People to operate and monitor

• No new funds

• Insufficient preparation

• Information gaps • Commitment

• Non-partner agencies and governments

• Vertical aid organizations

• Shifts in balance of power

• Conflict • Corruption

Group of 8(G8)

• Member states • Other countries • Existing agencies

• Initiative • Political support • Increased funding and compliance

• Summit • Financial obligation

• Increased ministers’ duties

• Non-compliance • Conflicting national and global interests

• Non-members • WHO and other UN agencies

• Civil society

• Inability to act without consensus

• Members’ needs prioritized

Global Health Fund • Donor and recipient governments

• Private donors

• Increased donor commitment

• Better funding strategies

• Increased human resource investment

• $12 billion per year

• Money gets rerouted to distal determinant of health

• Potential need for increased global public finance, like global taxes

• Reversal of progress made towards MDG 6

Biosecurity concert

• UN Security Council

• UN member states

• Coordinate biosecurity initiatives through existing legal instruments

• Moderate costs • Secretariat to support new UN committee

• Lack of belief in Security Council

• Countries who are not members of the UN Security Council

• Marginalize non-state actors

• Securitization of health


• Member states • Government • Development agencies

• Research • Accountability mechanisms

• Development programs

• Loss of other development initiatives

• Diverted funds and resources

• Lack of power • Lack of legitimacy • Lack of funding

• Existing development agencies

• Funders

• Addition to sea of overlapping organizations


• WHO as leader • All global health actors

• Establish networks through active participa-tion of actors

• Time consuming due to lack of direct leadership

• Lack of participa-tion of actors

• Competition between networks

• Actors unwilling to collaborate due to differing ideology

• Time costs lead to lack of action on time sensitive issues


• WHO & UN • National governments

• Civil society • Businesses

• Establish institutional structures for GANs

• Facilitate networking

• GAN Secretariats • Time for coordination

• Stakeholders unwilling to collaborate

• Actors pursue own agendas

• Funders • National governments

• Increased fragmentation and conflict among networks


• Government • Private sector • Foundations • Civil society

• Stakeholders commit to obligations

• Monitoring • Enforcement mechanisms

• Financial resources to fund activities for global health

• Loss of momentum and key players

• Lack of consensus

• Parties not invited to join, including private sector and civil society

• Discourages participation of high-income countries


• WHO • Donor countries • Recipient countries

• Support and ratification from the World Health Assembly

• Consistent, annual percentage of a donor states’ GNI

• May not receive adequate funding

• States that do not support multilateral approaches

• Overburdens recipient nations

• Short-term hindrance to economy


• WHO • States • Non-state actors

• WHO facilitates treaty negotiations

• States ratify treaties and fund activities

• Finances and technical expertise to implement laws

• Patchwork of conflicting laws

• Lack of priorities

• States or lobby groups that disagree with a proposal

• Survival needs neglected

• Priorities skewed toward wealthier state interests

Health impact Fund

• Government • Pharmaceutical industry

• Administrative body

• Create administration

• Global funding • Metrics

• $6 billion/yr • Administrative costs

• Monitoring & evaluation

• Limited funding • Reluctant firms • Assessment difficulty

• Governments as funders

• Anti-business activists

• Aid money given to for-profit firms

• Potential for gaming and corruption

table 3: implementation considerations for the thirteen Proposals for Global Health Governance Reform

Two school girls in Kochi, India. Jake Hirsch-Allen, 2006.

cHAPteR 1 HeALtH 8 (H8)

By Jennifer Nicolle and Madeleine Tye


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nthe Proposed Reform

The global health sector has recently experienced an increasing emergence of state and non-state actors, with varying areas of specialization. There has been a shift away from the singular role of United Nations bodies such as the World Health Organization (WHO) towards a multitude of players, resulting in increased disorder and decreased coordination. Not only has there been a rise in the number of actors and initiatives, there has been a clear divergence of their agendas.1 This is further complicated by inadequate monitoring of activities and a lack of transparency concerning funding, operations and progress. A growing concern is that this “revolution” in the global health field is actually contributing to problems rather than providing solutions, thereby increasing health disparities between the developing and developed world.2 The present disorder demonstrates the need for a new architecture to govern the complex field of global health. It is from this context that the “Health 8” or “H8” has emerged as a potential leader to govern global health.

The H8 looks to combine the individual efforts of eight influential actors in the current global health sphere. The collaborating groups include WHO; United Nations International Children’s Emergency Fund (UNICEF); Joint United Nations Program on HIV and AIDS (UNAIDS); United Nations Population Fund (UNFPA); World Bank; Global Alliance for Vaccines and Immunization (GAVI); Bill and Melinda Gates Foundation; and Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). The inaugural meeting of the H8 took place in July 2007, and the group has since established itself as an informal body that meets biannually to discuss challenges in global health. The

Abstract

the H8 constitutes a proposed model of governance that could respond to the current disorder within the domain of global health. established in 2007, the H8 is composed of eight influential global health players, and profits from the diverse capacities and specializations of its members. the nature of this body hinges on collaboration and coordination to facilitate prioritization and the establishment of common objectives. two of the H8’s fundamental areas of focus are the realization of the Millennium development Goals and health systems strengthening. this paper evaluates the H8’s ability to respond to the six grand challenges of global health, as defined by Gostin and Mok. it concludes the H8 has the capacity to do so. However, the H8’s leadership success in global health depends on increasing its visibility and accountability, and achieving a balance among its members’ powers.

12 << Health 8 (H8)

composition of the group transcends both the public and private sectors. Increased prominence of the H8 could affect the entire field of global health, potentially creating a ripple effect, so that decisions made by the H8 would influence other NGOs, as well as civil and private global health actors. Moreover, government policy could be influenced on multiple levels if H8 recommendations were incorporated into national and international policy.

The H8 provides the opportunity to increase communication between influential global health actors, thereby encouraging collective agenda-setting and joint prioritization. This could facilitate

effective and efficient realization of common objectives including progress towards the achievement of the health-related Millennium Development Goals (MDGs) and the strengthening of health systems.

This reform differs from previous global health governance proposals in that it focuses on joint leadership among eight specific actors, and relies on the notion of collaboration that is inherent to partnerships. Many past and current initiatives have aimed to create a completely new governing body, or reform existing bodies to take on a governance role. This proposal builds on established institutions and does not designate one singular body as

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Jake Hirsch-Allen, 2008.


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the leader. The H8 can be conceptualized as the combination of individual strengths of independent member organizations. Furthermore, the lessons learned from members’ past experiences, including project design and implementation, mandates and research, could contribute to H8 planning and priority-setting. These eight players in concert have the capacity to share ideas from their diverse backgrounds, and the limited number of actors may facilitate maintaining order and reaching consensus.

The financial cost of implementing this proposal is feasible. As an informal body with a loose governing framework,6 the H8 does not require significant start-up costs. However, the coordination and collaboration of eight distinct organizations requires significant investment of time for organization and planning. Associated costs will be mainly concerned with human resources and coordination, with both organizational leaders and staff involved.

evidence-informed Analysis of the Proposed Reform

At the inaugural H8 meeting in July 2007, the group recognized several pertinent challenges in the current global health sphere. They identified the need for a new approach to address the health-related MDGs, and the need to establish a sense of global urgency concerning the realization of these goals. The group acknowledged that the recent growing interest in health systems could provide an opportunity to establish a more systematic approach to health systems strengthening, and that contributions from both civil society and the private sector could play an important role in facilitating this new approach.3

The ideas communicated at this meeting indicate that the H8 has the capacity to collaborate and coordinate despite differing institutional frameworks and interests.

A woman washing dishes

in Vashist, India.


overview inputs outputs intended outcomes AssumptionsShort-term Long-term

Health 8 • Collaboration of 8 influential global health players for governance

• Member expertise • Human and financial resources

• Common agenda • Joint priorities • Publications

• Establish governance role • Improve coordination of field

• Strengthen health systems • Help meet MDGs • Leadership

• Member compliance • Power balance • Can gain influence

table 1: Key elements of the Health 8

14 << Health 8 (H8)

The body is still in a stage of infancy and therefore developing its role in the global health sphere. These two factors make it difficult to predict the future of the H8 as an effective governance body for global health. One approach that attempts to evaluate the success of the H8 as a global health leader is to examine how well the body could address the six grand challenges of global health governance as identified by Gostin and Mok.

The following evidence-informed examination of the H8 benefits from parallels that can be drawn between the H8 and the G8. The H8 has adopted a name that reflects its structural similarities to the G8 in terms of size and organizational architecture. Much like the G8, the H8

is composed of eight influential actors in its respective field. Furthermore, the authoritative role of the G8 allows the body to have a direct influence on decisions made in the international political arena, as will be outlined later. The H8 could have a similar function in the domain of global health if they successfully establish themselves as a leader. The following consists of an evaluation of the H8’s capacity to address the six grand challenges of global health governance.

1. the lack of global health leadership

No singular body has assumed a successful leadership role in the global health sphere,

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nindicating the need for a new form of leadership. Due to the complex nature of global health issues,8 uniting different perspectives may prove more successful in addressing these issues in their entirety. The H8 could constitute a legitimate form of leadership through its capacity to combine the knowledge, experiences and resources of eight influential global health players.

The nature of the partnership allows for actors to utilize different strengths, thereby contributing to overall leadership capacity. The WHO, for instance, has the capacity to write and implement international law concerning global health. As a public-private partnership, GAVI can help navigate the issues of working in a partnership setting. The Gates Foundation has vast financial resources that could be used to support H8 activities. UNFPA explicitly states the importance of culturally sensitive and human rights-based approaches to health initiatives, which could encourage the H8 to examine problems from diverse perspectives. UNFPA’s influence may also promote the protection of human rights in the development and implementation of H8 initiatives.12

That said, effective leadership can only be realized if all members take their roles within the H8 seriously. Up to this point, the H8 has functioned without binding documents to codify their partnership, founding principles or overarching objectives. The G8 has been criticized for the same absence of binding documentation; constitutional or founding legislation might illustrate the H8’s commitment to this model of governance and associated activities. Furthermore, the reflection of H8 decisions in the institutional frameworks of member organizations would demonstrate their compliance with H8 protocol and

could conceivably promote H8 resolutions across the entire field of global health.

The G8 represents a case where a small, elite group has gained the capacity to assert significant international influence. This influence has been largely attributed to its collective diplomatic, economic and military power. Despite its small structure, the G8 has achieved global visibility and has asserted itself as a global leader in influencing the decisions of important bodies such as the United Nations (UN) Security Council and the World Trade Organization.14 The H8 also represents a small, elite group within the global health sphere. Should it aspire to assume real leadership in global health, the H8 must capitalize on its strengths and become more visible. Increased accessibility to information pertaining to the H8 and its decisions, comparable to publications like G8 communiqués or Chair Summaries, could facilitate this process.

A woman selling soft

drinks in Manila,

Philippines. Jake Hirsch-Allen, 2006.

16 << Health 8 (H8)

2. the need to harness the creativity, energy and resources for global health

The fusion of diverse ideas stemming from individual experiences of H8 members in the global health field would foster new ideas and encourage creativity. At its July 2007 meeting, the H8 noted the importance of engaging the private sector and civil society. Among other things, it was noted that these two sectors could potentially help facilitate the delivery of health services and provide sources of funding for global health.3 This stated goal could promote the mobilization of civil society and other actors, informing them about pressing global health issues. However, there is little evidence that the H8 has taken serious steps to incorporate the private sector and civil society in its actions since its original recommendations. As the H8 is not particularly visible or accessible to the public at present, the group is not necessarily well placed to engage civil society at this stage. Nevertheless, there is value in civil society engagement to increase H8 visibility and promote social change.8

Furthermore, the involvement of private bodies such as pharmaceutical companies could be problematic, should this result in a divergence from established H8 targets.8 GAVI has demonstrated one way to overcome this problem. The pharmaceutical industry represents one seat on GAVI’s

16-member board; this representative’s expertise contributes to the diversity and knowledge of the board, but their power is limited by other participants, including UNICEF and the WHO.11

Collectively the H8 has overwhelming research, financial and institutional resources at its disposal. As recognized global health leaders,6 each of the H8 organizations has many contributors, including employees, volunteers and financial donors. Moreover, these members represent different areas of interest, ranging from social determinants of health to vaccinations and HIV/AIDS. Working as a collective, the H8 has a wider scope and greater resources than any of its members on an individual basis.1

If the H8 can capitalize on existing resources, its capacity to promote ideas and activities could extend to the entire field of global health, thereby creating value beyond the sum of its parts. In doing so, the H8 would have the potential to overcome global health challenges more efficiently.

3. the lack of collaboration and coordination among multiple players

The nature of this proposal emphasizes the collaboration and coordination of H8 member groups as a means of improving the efficiency and effectiveness of global health governance. There is a significant

1 2 3 4 5 6Global Health Leadership






Health 8 • Gain visibility, capitalize on members’ strengths

• Diverse ideas, institutional, financial, research resources

• Coordination and collabo-ration are central tenants of model

• Both established as areas of primary concern

• Could pro-mote prioriti-zation, funding presents challenges

• Greater transparency and evaluation tools necessary

table 2: How the Health 8 Addresses Six Grand challenges in Global Health Governance


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ndegree of overlap in the global health sphere between the objectives and interests of different actors. Collaboration could help minimize the duplication and disarray in current global health programs, activities and funding.8 According to the UN General Assembly’s December 2010 resolution on global health and foreign policy, progress in global health is dependent on coordination.

Prior to the H8’s inaugural meeting, many of the H8 members already actively contributed to the functioning of other group members. For example, the Gates Foundation has provided $1.5 billion to GAVI.16 Similarly, UNAIDS has received a significant portion of its funding from GFATM. The degree of pre-existing collaboration begs the question if and how participation in the H8 will change the nature of these relationships. Although financial resources such as that of the Bill and Melinda Gates Foundation could potentially benefit the H8, they could also be a cause for concern if finances dictate power and influence agendas and priorities. The Gates Foundation, among other prominent players, has been criticized for prioritizing health issues disproportionately with respect to other pressing global health concerns.8 Similarly, between 1996 and 2005 the annual international funding for HIV/AIDS increased from $300 million to more than $8 billion, whereas malaria and tuberculosis, the next two most significant diseases in terms of death rate, received less than $2 billion in funding per year combined.16

One criticism of the G8 that is also applicable to the H8 concerns the lack of representation inherent in a global body composed of only eight actors. It is unclear how H8 members were selected and why other significant global health actors

were excluded, such as the Red Cross and Médecins sans frontières (Doctors Without Borders). Moreover, four of the eight groups are UN bodies. In consideration of criticisms pertaining to the UN system’s capacity to mobilize adequate funding from members to achieve goals and meet deadlines,15 it is questionable whether the rest of the global health sphere would promote the goals of a UN-dominated body. Despite these criticisms, the small size of the H8 could facilitate opportunities for effective collaboration. The size, collective commitment to global health and selective membership contribute to the H8’s leadership potential,19 as these factors could assist the group’s capacity to reach consensus.

4. the neglect of basic survival needs and health systems strengthening

Three of the objectives explicitly stated by the H8 at their inaugural meeting in 2007 include: 1) the critical need to strengthen health systems; 2) establishing a sense of

A Tibetan boy in Dharmshalla, India. Jake Hirsch-Allen, 2006.

18 << Health 8 (H8)

urgency towards the realization of the health-related MDGs; and 3) modifying institutional practices to meet the MDGs.3 The H8’s establishment of these objectives demonstrates its recognition of the neglect for basic survival needs and health systems strengthening in the current global health arena. In making these areas part of its focus, the H8 has shown its willingness to prioritize basic survival needs and health systems strengthening. However, it is not completely clear how the H8 is proceeding.

In early 2010, the H8 published an article calling for increased collection and monitoring of global health statistics. The article asserts that the collection of accurate health statistics would allow for better monitoring of the progress and performance of health policies and programs, and evaluation of their impact. The H8 suggests that better data collection is essential to the realization of the MDGs and other significant global health goals, such as health systems strengthening.20 This demonstrates that the H8 is actively working

to follow through with its original objectives pertaining to the realization of the MDGs and health systems strengthening. Should the H8 become a recognized global health leader, it could influence other actors to address the current neglect for basic health needs and health systems strengthening.

5. the issue of funding and priority setting

Despite a recent unprecedented rise in funding for global health, still more money is needed to adequately address current global health problems. As it stands, the establishment of the H8 itself does not provide an apparent solution to the current lack of funding in global health. For example, the WHO relies almost entirely on its member states for funding.8 The functioning of other member groups such as GAVI and UNAIDS is reliant on financial support from other H8 members.16 Despite the H8’s inclusion of the Gates Foundation, a private, wealthy body that represents one of

Footbridge to the ancient city of

Ava, Myanmar.Steven J. Hoffman, 2009.


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nthe biggest global health donors, the lack of funding in global health will persist.

The H8 will conceivably need to gain visibility and establish itself as an effective global health leader in order to stand the chance of garnering widespread support. The collaboration of diverse members who represent both the donors and recipients of global health funding could result in increased opportunities to generate new funds. Another desired outcome of this collaboration is the reduction of current overlap between existing global health initiatives.8 This should result in a redirection and more effective use of financial resources in global health.

The nature of the partnership promotes collaboration in a way that encourages collective prioritization among H8 members. The targets established at the H8’s inaugural meeting in 2007 respond to current global health concerns such as health systems

strengthening and the coordination of actors.3 This demonstrates a willingness to establish common priorities aligned with pertinent global health needs. However, willingness does not always translate into reality, especially given differences in the members’ capacities and areas of specialization.13 Thus, priority setting could constitute a significant challenge faced by the H8.

Furthermore, the composition of the H8 presents the possibility that certain issues may be given disproportionate attention based on the interests or financial capacity of member parties. For example, disease-specific issues such as HIV/AIDS may be prioritized above issues pertaining to the social determinants of health, simply because there are member organizations that advocate specifically for HIV/AIDS. Also, the pre-existing relationships between organizations, such as the Gates

A Sikh man by the Golden

Temple in Amritsar, India


20 << Health 8 (H8)

Foundation’s funding of GAVI, may result in a position of dominance when it comes to priority-setting. If an organization is receiving substantial funding from another, recipients may consider it in their best interest to align their goals with that of the funder to guarantee the income. For example, funding from major global health donors including GFATM, the World Bank and the Gates Foundation, has rendered the health ministries of Kenya, Tanzania and Uganda highly dependent on donor funding. Consequently, ministry priorities are influenced by donor priorities, rather than the immediate needs of the respective countries.22

6. the need for accountability, transparency, monitoring and evaluation

Individual H8 members such as the Gates Foundation, GFATM and the World Bank have been criticized for their lack of transparency. 22 This lack of transparency is a common criticism of the greater global health community,21 and raises questions pertaining to the transparency of the H8 as a whole.

The H8 stands in contrast to the G8, which has publicized summits and publishes post-summit reports detailing newly established commitments for members.15

Although H8 meetings are supposed to occur biannually,4 there is a clear lack of evidence documenting meetings and outcomes, which compromises the body’s

A scene along the docks in Bangkok, Thailand.



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nwidespread accessibility. As well, the H8 has a limited capacity to be accountable to civil society due to its degree of separation from the general public. At present, the public is not involved in the selection of H8 representatives or involved in H8 decision making or priority setting.

It could be argued that the collaborative nature of the H8 fosters interdependence between member organizations and encourages mutual accountability. The actions of one actor could impact the collective, which would make them accountable to the rest of the H8 rather than just their own organization. However, the question remains of whether this collaboration provides adequate incentive for individual H8 members to increase their individual accountability.

The previously mentioned H8 publication concerning global health statistics explicitly states that increased monitoring and evaluation of health statistics would improve accountability at country and global levels.20 This illustrates the H8’s desire to improve global health accountability by using data to monitor global health initiatives and assess their results. That said, there is a significant difference between advocating for monitoring, evaluation and accountability versus truly implicating a transparent process. Considering the recent date of the publication, its impact remains unclear.

Perhaps the H8 could further improve transparency and accountability through the establishment of formalized follow-through mechanisms to help promote accountability and monitoring. The G8 Research Group is one example of such a mechanism; it works to evaluate and analyze the G8 members’ compliance with and progress towards meeting group commitments in the year following each summit.15 In addition, the G8 published the Muskoka Accountability Report in 2010, which assesses G8 members’ compliance with and the results of commitments made for development over the last 30 years. Even though these enforcement mechanisms may not make the G8 completely accountable, the idea of a mechanism that encourages accountability and monitors progress could be mimicked by the H8.

conclusion

The H8 demonstrates the potential to be an effective model for global health governance. However, as outlined in this paper, significant progress must be made in order for the H8 to exert such influence in the domain of global health. The H8 has the capacity to address the six grand challenges of global health, but its actions in the future will dictate the extent to which this will be realized. The collaboration and coordination which form the basis for this group demand that actors work in concert

Key Players tasks costs Risks opposition Possible Harms

Health 8 • 8 key players in global health

• Bi-annual forum • Align agendas • Consensus • Compliance

• Coordination costs • Inexpensive

• Not accepted as leader • Lack of compliance

• Civil society • Private actors • Excluded • Important actors

• Sever ties within H8 • Further diversion of resources & agendas

table 3: implementation considerations for the Health 8

22 << Health 8 (H8)

to set and achieve common objectives. Due to the relatively recent development of the H8, the extent of the group’s collaboration has yet to be determined and will be better established should the group solidify its role in global health. A current lack of transparency is detracting from the H8’s capacity to exert influence over the field of global health. This could be improved by employing follow-through mechanisms to ensure accountability, as the G8 has

done. Moreover, the unequal financial capacities of member parties may result in power imbalances within the group. The combination of strengths and knowledge contributed from its members enhances the H8’s ability to address critical global health issues such as improving health systems strengthening and the realization of the health-related MDGs.

Key Messages

» The H8 could influence the entire global health sphere should it gain a significant position of leadership.

» To assume a position of leadership, the H8 must increase its visibility and overcome obstacles such as members’ varying interests and disproportionate financial power.

» H8 members must collaborate to more effectively address pertinent global health issues such as the Millennium Development Goals and health systems strengthening.

» Future actions of the H8 will demonstrate how effectively this coordinating mechanism is able to address the grand challenges of global health governance.


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nReferences1 Editorial. Who runs global health? Lancet. 2009 Jun 20; 373(9681): 2083. 2 Aginam O. The nineteenth century colonial fingerprints on public health diplomacy: A Postcolonial View. LGD

[Internet]. 2003 Apr [cited 2010 Nov 14]; 1: 1-12. Available from : http://www2.warwick.ac.uk/fac/soc/law/elj/lgd/2003_1/aginam

3 World Health Organization [Internet]. Geneva: World Health Organization; c2007 [updated 2010; cited 2010 Nov 20]. Informal meeting of global health leaders; [about 2 screens]. Available from: http://www.who.int/dg/reports/31072007/en/index.html

4 UNICEF. The State of the World’s Children 2009: Maternal and Newborn Health. New York: United Nations International Children’s Emergency Fund, 2008.

5 Doughton S. Global-health stars converge on Seattle. The Seattle Times [Internet]. 2009 Jun 17 [Cited 2009 Jun 17]; Available from: http://seattletimes.nwsource.com/html/health/2009348027_healthdavos17m0.html

6 Reich MR, Takemi K. G8 and strengthening of health systems: Follow-up to the Toyaka Summit. Lancet. 2009 Feb 7; 733 (9662): 508 –15.

7 Birn A. The stages of international (global) health: Histories of success or successes of history? Glob Public Hlth, Rgph. 2009 Jan; 4(1): 50-68.

8 Gostin LO, Mok EA. Grand challenges in global health governance. Br Med Bull. 2009; 90(1): 7-18.9 Hajnal PI, Kirton JJ. The evolving role and agenda of the G7/G8: a North American perspective [Internet]. NIRA

Review; Spring 2000 [cited 2010 Nov 15]. Available from http://www.g7.utoronto.ca/scholar/hajnal_nira.pdf10 Taylor AL. Global governance, international health law and WHO: looking towards the future. Bulletin of the

WHO. 2002; 80 (12): 975-80. 11 Forman S, Segaar D. New coalitions for global governance: the changing dynamics of multilateralism. Global

Governance. 2006 Apr; 12 (2): 205-2512 United Nations Population Fund (UNFPA). Using cultural fluency for greater effectiveness. Available from http://

www.unfpa.org/culture/ (Accessed November 2010) 13 Hajnal PI. Can civil society influence G8 accountability? Centre for the Study of Globalisation and Regionalisation

(CSGR) Working Paper Series, University of Warwick 2007; 235/07: 1 – 31.14 Barry T. G8 and global governance [Internet]. Washington: Foreign Policy in Focus; 2005 Oct 5 [cited 2010 Dec

6]. Available from: http://www.fpif.org/reports/g8_and_global_governance15 Kirton JJ, Roudev N, Sunderland L. Making G8 leaders deliver: an analysis of compliance and health commitments,

1996–2006. Bulletin of the WHO. 2007; 85 (3): 192 – 9. 16 Cohen J. The new world of global health. Science. 2006 Jan 13; 311 (5758): 162-7.17 United Nations General Assembly (UN GA). Global health and foreign policy. New York: UN GA, 2010. UN GA

publication A/65/L.27. 18 Joint United Nations Program on HIV/AIDS (UNAIDS). UNAIDS partnership with the Global Fund to Fight

AIDS, Tuberculosis and Malaria. Available from www.unaids.org/enPartnerhsips/Global+Fund+to+Fight+AIDS+TB+Malaria/default.asp (Accessed November 2010)

19 Kirton JJ, Daniels JP, Freytag A. Guiding global order: G8 governance in the Twenty-First Century. Brookfield: Ashgate; 2000.

20 Chan M, Kazatonkine M, Lob-Levyt J, Obaid T, Schweizer J, Sidibe M, et al. Call for action on health data from eight global health agencies. PLoS Medicine. 2010 Jan 26; 7(1): 1-4.

21 Garrett L. The Challenge of Global Health. Foreign Affairs. 2007 Jan; 86 (1) :14-38. 22 Sridhar D, Batniji, R. Misfinancing global health: a case for transparency in disbursements and decision making.

Lancet. 2008 Sept 27; 372 (9644):1185-9123 Benner T, Reinicke WH, Witte JM. Multisectoral networks in global governance: towards a pluralistic system of

accountability. Government and Opposition. 2004; 92 (2): 191-210.24 Gleicher D. The G8 and global health: getting hip with the times [Internet]. Global Health Europe. 2010 July

2 [cited 2010 Dec 10]. Available from: http://www.globalhealtheurope.org/index.php?option=com_content&view=article&id=308:the-g8-and-global-health-getting-hip-with-the-times&catid=60:your-opinion&Itemid=108

World Health Organization Headquarters in Geneva, Switzerland. Steven J. Hoffman, 2005.

cHAPteR 2 coMMittee c oF tHe WoRLd HeALtH ASSeMBLy

By Shohinee Sarma


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nintroduction

The World Health Organization (WHO) has been undergoing a transition in recent years and its role as the primary authoritative body on international health has diminished.1 Globalization has changed lifestyles and heightened the rate at which communicable diseases spread across borders, and health is increasingly being defined as a global public good. As a result, the arena of global health governance is no longer limited to states and the World Health Organization. Other bodies have grown much larger in power and resources, including private foundations such as the Bill and Melinda Gates Foundation, institutions such as the World Bank, UNAIDS, UNICEF and the UN Population Fund, and public-private partnerships such as the Global Alliance for Vaccines and Immunizations (GAVI) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM).1 Although global health funding has increased dramatically, coordination between these organizations is limited. Program funding is mainly disease-specific and crisis-initiated, which can lead to inefficiencies, overlap and a narrow approach to resolving health challenges.2 Current global health needs point toward coordination between stakeholders and increased input from various players in the decision-making, funding and delivery spheres. These key players include government agencies, civil society organizations, local and international non-governmental organizations (NGOs), academics and donors. The proposal for a Committee C of the WHO aims to integrate these various organizations within a structured forum to debate and adopt common strategies for global health.

Abstract

Globalization has reduced the role of the World Health organization and introduced multiple new players in the global health governance sphere. A proposal for a committee c of the World Health Assembly has been published; it aims to assemble various stakeholders including civil society groups in the global health decision-making process. this review critically examines this proposal and evaluates whether committee c will be able to fill leadership gaps. it also examines whether committee c can address current global health challenges such as the lack of coordination between various actors. the review concludes by assessing the political attractiveness and economic feasibility of committee c, and outlines areas of concern that will slow its implementation.

26 << Committee C of the World Health Assembly

the needs of vulnerable communities.6 Committee C would also place WHO, with its scientific and technical leadership, at the forefront of global health decision-making.6 Silberschmidt and Kickbusch point out that the WHO has the constitutional mandate to be the “directing and coordinating authority on international health work”, and “to establish and maintain effective collaboration with the United Nations, specialized agencies, governmental health administrations, professional groups and such other organizations.”7 For these reasons, it is argued that the WHO is the appropriate body for tackling the unique health challenges of the 21st century in a holistic and integrated manner.7

Key elements of the Proposal

The proposed Committee C mechanism would exist as a part of the WHO’s annual World Health Assembly (WHA). The WHA brings together health delegations from 193 member states, and has the

History of the Proposal

The need for a coordinating body in global health has been recognized, with initiatives such as the Health 8 (H8) and the International Health Partnership (IHP+) established.3 Similarly, the Global Fund and the Health Impact Fund have been proposed to discuss global health funding priorities.4,5 Although these initiatives include foundations, partnerships and bilateral and multilateral agencies, they do not draw upon the resources of intergovernmental and non-governmental organizations. Gaudenz Silberschmidt and Ilona Kickbusch have together published two seminal papers outlining these gaps in global health governance.6,7 They propose the creation of a Committee C of the World Health Assembly to address these gaps. The proposed Committee C would include the major stakeholders in global health – member states, large foundations, multinational health networks, private industries, and particularly NGOs and civil society organizations – that represent

World Health Assembly – Panel

on H1N1.Eric Bridiers


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nAppendix A, Figure 1), whereby negotiations occur formally in committee and informally outside of committee, will ensure consensus building between member states and funding parties. 7 Advocacy and lobbying by NGOs and private sector industries would also occur under the auspices of the WHA. 7

evidence-informed Analysis of the Proposal

The primary goal of Committee C is to form a governing body of the WHO that allows interaction between member states and the various global health stakeholders. The proposed Committee C could create protocols and draft treaties that direct global health organizations on how to handle emerging health and development challenges. Current global health challenges include: 1) the lack of global health leadership; 2) the need to harness creativity, energy and resources for global health; 3) the need for collaboration and coordination of multiple players; 4) the neglect of basic survival needs and health systems strengthening; 5) the lack of funding and priority setting; and 6) the need for accountability, transparency, monitoring and enforcement.10 A critical review of how Committee C would address each of these challenges would be beneficial in evaluating its success as a global health decision-making body.

authority to adopt binding resolutions on international health.8 In the past, the Framework Convention on Tobacco Control and the WHO’s International Health Regulations were debated and adopted through the WHA.8,9 The process of debating and drafting resolutions occurs within the WHA’s two main plenary committees – Committee A and Committee B. Committee A is primarily involved with WHO programming. Committee B deals with budget and administrative concerns.6 Committee C would operate alongside these two committees and provide a forum for global health organizations to voice themselves alongside member states. State diplomats will already be present at Geneva for the Assembly; NGOs, civil society organizations, foundations and pharmaceutical firms could send their representatives to be part of Committee C discussions. The WHO Director General would decide which organizations are to be present, and the Executive Board would accept proposals and set the Committee C agenda for the upcoming WHA meeting.6 It is important to note that Committee C would still preserve the sovereign role of state-based health delegations in the voting process. Non-state actors would not get the right to vote within Committee C, but they could influence and even draft resolution points that would be annexed to resolutions submitted by national delegations.6 This type of polylateral diplomacy (Refer to


WHo committee c

• WHO negotiations to include civil society in decisions

• Positive diplomacy between actors • Diverse proposals

• Decisions by various players • Better coordination

• Alignment of goals • Better collaboration & leadership

• Reduced fragmentation • Both donor & recipient accountability

• Donors do not have priority • Civil society has equal voice

table 1: Key elements of the committee c Proposal


foundations.6 Many of these organizations also rely on links with the WHO, especially for country-level operations.6 Committee C would formalize these relationships and set the WHO as the primary leader in global health decision-making.

On the other hand, Committee C decisions may be influenced by those with the largest share of funding resources. Since only member states can vote, organizations with greater lobbying power may have higher chances of annexing their interests to resolutions. Although private donors such as the Gates Foundation are prohibited from lobbying11, multinational pharmaceutical companies may leverage lobbying power on member states to achieve their interests.12 Competition between groups may create ruptures in the decision-making process and could result in fragmented and biased leadership. The WHO’s Executive Board, which decides which organizations are to be present at the forum, would find it difficult to limit the divides given the

the lack of global health leadership

The World Health Organization was first created by the United Nations in 1948 with the directive of being the primary “directing and coordinating authority for health.”7 It has been provided with powerful legal instruments for enforcing health norms and standards, such as the ability to create legally binding conventions and codes of practices.8 Committee C would fit within this decision-making mechanism; it could draft treaties and codes of practice with inputs from both governments and non-state actors. It would thus act as a “superstructural node” that coordinates issues of hard and soft power in global health through the process of networked governance.7 This form of governance would draw upon knowledge and leadership from organizations at every level of global health – from grassroots NGOs to large pharmaceutical companies to research think tanks and donor

Appendix A

Figure 1: Committee C polylateral diplomacy.


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nneeded resources and imaginative ideas. And civil society has demonstrated the capacity for helping those within their communities and advocating for social change.“ 10

However, this diversity can only be well utilized if there is positive engagement between parties. Otherwise conflicting and overlapping interests would increase costs and reduce health outcomes. Committee C requires a mechanism that evaluates the positive and negative effects of different actors, and conflicts of interest need to be taken into account. For instance, a large corporation selling low-cost junk food would be inherently at odds with an NGO advocating for a supposed “right to healthy food.”14 Yet if both parties are present at Committee C, dialogue on the topic would be divided.

complex array of participating organizations. Committee C has the potential to fill in gaps in global health leadership, but differences in priorities between donor and recipient nations may split the decision-making process .13

need to harness creativity, energy and resources for global health

The number of different actors involved in Committee C would add to the diversity and creativity of research and response. For instance, Gostin writes that:

“Businesses can offer innovations in pharmaceuticals, vaccines and medical devices; producing and selling healthier foods and safer products and creating healthier and safer places to work. Philanthropists can provide much

A market in Manila,

Philippines. Jake Hirsch-Allen, 2006.


Stakeholders may have different priorities and motives for funding global health programs. These differences are exacerbated in the development-related aspect of global health.7 The global health landscape is vast, and includes other topics besides health and development challenges. It is in these areas that coordination is more likely to occur between various actors.7 For instance, high-income countries such as Canada face health burdens for a rapidly aging population.16 Member states with similar health burdens can collaborate to form national strategies and solicit input from groups such as the Alzheimer Society of Canada.16

In contrast, coordination on health topics in relation to low- and middle-income countries may be limited due to differences in political ideologies between donors and recipients. For instance, the United States President’s Emergency Plan for AIDS Relief (PEPFAR) mainly funds abstinence-related AIDS reduction initiatives around the world.17 Grassroots organizations working with adolescents may not agree

Moreover, the WHO has a history of pandering to political interests as evidenced by WHO programs during the Cold War.1 Even now, organizations with political clout may find it relatively easier to garner monetary and public support for their interests. The opinions of these organizations could hold more sway among delegations in Committee C, which makes it particularly important to have other voices present. Instead of alienating advocacy groups and civil society organizations from the decision-making process (as evidenced by protests during WTO, G8 and G20 events), their voices could be engaged and used constructively as part of the overall discussion.15

the need for collaboration and coordination of multiple players

There is a bewildering amount of fragmentation and duplication in funding, agenda-setting and initiatives offered by different global health organizations.

World Health Assembly –

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organizations and provide sustainable health care.18 Competition between international NGOs and local healthcare providers often creates disincentives for local efforts to be sustainable. The Paris Declaration on Aid Effectiveness signed in 2005 represented the first time that recipient countries and NGOs had the voice to express such concerns.2 A forum such as Committee C could build upon the Declaration by offering civil society organizations, local governments and international aid organizations direct and formal audience with large multinational donors to discuss these concerns and avoid future overlap.

issue of funding and priority-setting

Donor countries and international aid organizations have primary responsibility for deciding what projects to fund, with some informal input from recipient countries and grassroots organizations through grant solicitations.11 Committee C would be the first time in history that civil society is able to dictate funding priorities directly to donors and thus bridge the gaps in understanding. However, critics of Committee C claim that the ambiguity in the committee’s structure will likely

with these strict abstinence policies.17 Coordination between these groups will remain minimal whether discussions take place within or outside Committee C. This lack of coordination may result in ineffective programming, and health outcomes may be jeopardized.

neglect of basic survival needs and health systems strengthening

Global health funding has increased over the years, and there are currently more than 70 global health partnerships each with its own specific target.18 The plethora of donors has led to global health funding being disease-focused and fragmented. For instance, the Gates Foundation and the Global Fund focus mainly on infectious diseases such as malaria, tuberculosis and HIV/AIDS.11 Similarly, the Global Alliance for Vaccines and Immunization (GAVI) is primarily involved with immunization and vaccination projects.19 Often, disease-based initiatives are not sufficient in overcoming bottlenecks that prevent access to health care in low- and middle-income nations. An emphasis on overall health systems strengthening is important in order to decrease long-term reliance on foreign







WHo committee c

• Form “su-perstructural node” that sets WHO at centre

• Assemble various players from governance and delivery spheres

• Employ polylateral diplomacy for consensus-building

• Limit competition between local government& international NGOs

• Civil society gives direct input to donors on funding priorities

• Increase in accountability from donors to recipients & vice versa

table 2: How the WHo committee c Addresses Six Grand challenges in Global Health Governance


in funding and implementation will both be present. However, critics suggest that the increase in accountability will only be expected in one direction: by donors from developing nations.13 There is also a need to increase accountability from donors to recipient communities in order to strengthen overall health and development commitments.13 In her book Dead Aid, Zambian economist Dambisa Moyo writes that in the past 50 years, more than $1 trillion of development aid has been transferred to low-income regions in Africa, with little or no tangible results. Dependency on aid has increased over the years and the lack of accountability by international aid agencies has made this model of development difficult.23 This specific model of development assistance also extends to development-related global health funding, which requires greater accountability on the part of donors. Funding for humanitarian crises or disaster-relief, however, does not fall in this category of long-term development aid and will most likely continue to be donor driven.23 Leaders proposing the creation of Committee C suggest three main strategies to ensure transparency and accountability: 1) operative mechanisms monitoring on-

make it easier for donors and international agencies to coordinate and control the funding agenda. Influential non-state actors such as the Gates Foundation may create an imbalance in the decision-making process, especially since the Foundation’s budget is often higher than the GDP of entire nations.11 For example, the Gates Foundation has donated more than $14 billion for medical research and global health projects since 1994.11 Overall development assistance from western nations has also added to this large fund.20 Recipient countries may find it difficult to challenge both wealthy member states and international foundations at the same time, and issues that are not priorities for donors (non-communicable diseases, maternal health, mental health and health infrastructure) may be left out of the picture during Committee C discussions.21, 22

need for accountability, transparency, monitoring and enforcement

Proponents of the Committee C proposal suggest that coordination between different actors will increase transparency and accountability as organizations involved

Men playing soccer in Koh

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nsociety perspectives on health topics through workshops, discussions and progress reports; some nations could thus view their presence in Committee C as redundant.25 Although non-state actors do not get voting power in Committee C, coordination between them could create blocs and coalitions that result in strong negotiating forces. These forces could threaten the sovereignty of certain member states during Committee C debates.

Feasibility and Practicality for implementation

The proposed Committee C could be implemented rapidly if the political will were mobilized. The mechanism does not need significant legal changes since the constitutional mandate for implementing Committee C already exists. The WHA already meets annually and has the convening power to bring together multiple stakeholders formally and informally at its venues for polylateral diplomacy.7 Thus, the overall costs of creating Committee C are not significant since individual organizations and member states pay individually to attend. On the other hand, smaller grassroots organizations may find it difficult to bear the costs of travelling to Geneva, which may mean that only large organizations that can handle the costs will be represented at Committee C. Committee C’s primary objectives would be jeopardized

ground distribution, delivery and research; 2) normative mechanisms aligning the philosophies and standards between actors; and 3) strategic mechanisms that specify policies and agendas to reach global health aims. These ideas are a step in the right direction, but those proposing Committee C need to keep in mind that as the number of stakeholders increase, the sense of responsibility on the part of each towards the whole may decrease.

Political Attractiveness

The political attractiveness of Committee C is dependent upon which organizations are selected by the Director General to be represented. Overall, civil society organizations and grassroots NGOs will find Committee C politically attractive since it will give them direct audience with both member states and multinational non-state actors in a formal setting. This will allow for multilateral debate on the agenda-setting process rather than decisions being made primarily by donor states with informal input from recipient organizations.24 Large donor agencies will also consider Committee C attractive as it will provide room for increased involvement at a formal level. Member states, however, could regard Committee C as minimizing the role of governments in global health decision-making. Governments already solicit civil


WHo committee c

• Executive Board • Member states • Donors, civil society

• Harness political will, draft WHO resolution

• Part of WHA costs • Actors pay to attend

• Smaller organizations may not attend due to travel costs

• Member states may oppose to protect sovereignty in decisions

• Actors with political and economic influence will bias decisions

table 3: implementation considerations for the WHo committee c


society organizations, recipient nations and grassroots NGOs may provide means for outlining health priorities for low- and middle-income countries. However, although the costs of Committee C are covered by the annual World Health Assembly, only organizations that can afford to travel to Geneva will be able to attend. If Committee C gains political momentum from all stakeholders (NGOs, civil society groups, multinational foundations and companies, and members states), there is a high chance that it will be established within the next few years.

if smaller grassroots organizations are not represented. Moreover, the ambiguity of the Committee’s resolution-annexing process and the exact role of NGOs and civil society organizations in the debate process need to be addressed before there is extensive political support for its establishment during upcoming WHA meetings.

conclusion

The creation of a Committee C of the World Health Assembly would establish the WHO as the primary decision-making body in global health. It would also provide the necessary forum for coordination between the multitude of players in global health funding and agenda-setting. However, such coordination may be biased towards wealthy nations and donor organizations. There could be increased collaboration on global health burdens that affect high-income countries. Coalition efforts between civil

Key Messages

» Committee C negotiations would reflect polylateral diplomacy, whereby consensus-building would occur through a process of networked governance between various parties.

» Committee C would likely constructively engage civil society groups and grassroots organizations in formal debates, instead of alienating them from the decision-making process.

» Organizations with greater political influence or funding resources may receive more leadership opportunities and bias the decision-making scene.

» Governments will retain state sovereignty in the voting process as non-state actors do not receive voting rights.

» Only large organizations may be able to bear the costs of participating in Committee C.


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nReferences1 Brown TM, Cueto M, Fee E. The World Health Organization and the transition from “international” to “global”

public health. Am J of Public Health. 2006 Jan; 96: 62-72. 2 Pfeiffer J, Johnson W, Fort M, Shakow A, Hagopian A, Gloyd S, Gimbel-Sherr K. Strengthening health systems in

poor countries: A code of conduct for nongovernmental organizations. Am J Public Health. 2008 Dec; 98(12): 2135-2140.

3 Labonte R and Marriott A. IHP+: Little progress in accountability or just little progress? Lancet. 2010 May; 375: 1505-1507.

4 Cometto G, Ooms G, Starrs A, Zeitz P. A global fund for the health MDGs? Lancet. 2009 May; 373:1500-1502. 5 Banerjee A, Hollis A, Pogge T. The Health Impact Fund: incentives for improving access to medicines. Lancet. 2010

Jan; 375:166-169.6 Silberschmidt G, Matheson D, Kickbusch I. Creating a committee C of the World Health Assembly. Lancet. 2008

May; 371: 1483-1486. 7 Kickbusch I, Hein W, Silberschmidt G. Addressing global health governance challenges through a new mechanism: the

proposal for a Committee C of the World Health Assembly. J Law Med Ethics [Internet]. 2010 [cited 2010 Dec 20]; 38(3):550-563. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1748-720X.2010.00511.x/abstract

8 Johnson T. The World Health Organization. Council on Foreign Relations Backgrounder [Internet]. 2009 Aug [cited 2010 Dec 20]; 1-5. Available from: http://www.cfr.org/publication/20003

9 People’s Health Movement, Medact, Global Equity Gauge Alliance. Global health watch 2: An alternative world health report [Internet]. New York: Zed Books Ltd.; 2008 [cited 2010 Dec 20];. Available from: http://www.who.int/pmnch/topics/health_systems/globalhealthwatch2/en/index.html

10 Gostin LO and Mok EA. Grand challenges in global health governance. Br Med Bull. 2009 Apr; 90(1): 7-18. 11 Bill and Melinda Gates Foundation [Internet]. Seattle: Bill and Melinda Gates Foundation; 2010 [cited 2010 Dec

20]. Available from: http://www.gatesfoundation.org/grantseeker/Pages/overview.aspx12 Pogge T. Access to medicines. Pub Health Ethics [Internet]. 2008 [cited 2010 Dec 20]; 1(2):81. Available from:

http://phe.oxfordjournals.org/content/1/2/73.full.pdf+html13 Batniji, R. Coordination and accountability in the World Health Assembly. Lancet. 2008 Sept; 372 (9641): 805. 14 World Food Programme. Nigeria: The poor have a right to healthy food –Ruma. Abuja: World Food Programme

[Internet]; 2009 Feb [cited 2010 Dec 20]. Available from: http://www.wfp.org/content/nigeria-poor-have-right-healthy-food-ruma.

15 Intini J, Belluz J, Dehaas J, Findlay S. The fallout from Toronto’s G20 protests. MacLeans [Internet]; 2008 July [cited 2010 Dec 20]. Available from: http://www2.macleans.ca/2010/07/08/showdown-in-the-streets/.

16 Picard A. Why Canada needs a national strategy on dementia. Globe and Mail [Internet]; 2010 Sept [cited 2010 Dec 20]. Available from: http://www.globalaging.org/health/world/2010/strategyC.htm.

17 Santelli J, Ott MA, Lyon M, Rogers J, Summers D, Scheifer R. Abstinence and abstinence-only education: A review of US policies and programs. J Adolescent Health [Internet]. 2006 [cited 2010 Dec 20]; 38(1):72-81. Available from: http://www.jahonline.org/article/S1054-139X(05)00467-2/abstract

18 Lorenz N. Effectiveness of global health partnerships: will the past repeat itself ? Bull World Health Organ. 2007 Jul; 85(7):567.

19 GAVI Alliance [Internet]. Geneva: GAVI Alliance; 2010 [cited 2010 Dec 20]. Available from: http://www.gavialliance.org/contact/index.php

20 Who runs global health? Lancet. 2009 June; 373:2083.21 Shiffman J and Smith S. Generation of political priority for global health initiatives: a framework and case-study of

maternal mortality. Lancet. 2007 Oct; 370. 22 Tomlinson M, Rudan I, Saxena S, Swartz L, Tsai AC, Patel V. Setting priorities for global mental health research.

Bull World Health Organ [Internet]. 2009 Jun [cited 2010 Dec 20]; 87(6): 405-484. Available from: http://www.who.int/bulletin/volumes/87/6/08-054353/en/

23 Moyo D. Dead Aid: Why aid is not working and how there is a better way for Africa. Farrar, Strauss and Giroux; 2009 March [cited 2010 Dec 20].

24 Sanders D, Labonte R, Baum F, Chopra M. Making research matter: a civil society perspective on health research. Bull World Health Organ [Internet]. 2004 Jul [[cited 2010 Dec 20].; 82(10): 757-763. Available from: http://www.scielosp.org/scielo.php?script=sci_pdf&pid=S0042-96862004001000011&lng=en&nrm=iso&tlng=en

25 Guglielmo, R. Civil society monitors governments’ progress. Global Health Council [Internet]; 2006 Jun [cited 2010 Dec 20]. Available from: http://www.globalhealth.org/publications/article.php3?id=1488

Children playing on the beach in Sihanoukville, Cambodia. Jake Hirsch-Allen, 2010.

cHAPteR 3 inteRnAtionAL HeALtH PARtneRSHiP (iHP+)

By Katryna Stemmler and Carolyn Travers


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nthe Reform

History of the Reform

On September 5, 2007, U.K. Prime Minister Gordon Brown together with representatives from leading international health agencies from developed and developing countries launched the International Health Partnership and Related Initiatives (IHP+).1 The primary aim of IHP+ is to accelerate health progress on a global scale and achieve better health results by assembling donor countries and other partners in development around a single country-led national health strategy. IHP+ is open to all developed and developing country governments, development agencies and civil society organizations willing to sign and agree to the commitments of the IHP+ Global Compact.2

In 2005, more than 100 ministers and heads of agencies signed the Paris Declaration, committing their countries and organizations to improve aid harmonization and to better monitor indicators of aid effectiveness. This work was built upon in 2008 through the signing of the Accra Agenda for Action, which further defined the international goal to work towards improving health services and health outcomes. The IHP+ is designed to put the principles agreed to in Paris and Accra into practice.2

What the Reform Addresses

International health is a crowded field, and although health aid to developing countries has reached approximately US$15.5 billion, much of this funding is tied to individual diseases and is delivered outside of the recipient countries’ planning and budgeting systems.3,4 This interferes with

Abstract

the international Health Partnership and Related initiatives (iHP+) was launched in 2007 as a mechanism through which global health leaders could reaffirm their commitment to increasing aid effectiveness. the iHP+ aims to align donors around single, country-led national health strategies in order to achieve better health outcomes. By increasing coordination among players, focusing on health system strengthening, and ensuring sustainable financing commitments for developing nations, the iHP+ has the potential to address a number of the grand challenges in global health governance. the existing partnership faces many barriers to addressing these challenges. the lack of incentives for adherence as well as insufficient monitoring and evaluation protocols could curtail the progress of the partnership. the lack of involvement from non-iHP+ members may lead to difficulties in increasing coordination. overall, the iHP+ could be crucial to achieving aid effectiveness and better health outcomes. However, further changes must be made before this possibility can be realized.

38 << International Health Partnership (IHP+)

IHP+ aims to reduce the administrative burden on health ministries and increase donor impact.

Key elements of Reform

Signatories to the IHP+ framework currently include 24 low-income countries, 13 bilateral donors, and 12 international organizations and foundations (refer to Appendix for list of members).1 In becoming a member, each country or partner is demonstrating its commitment to changing behaviour in line with the Global Compact. It is also expected that members commit to financing through time-bound, results-oriented Country Compacts. By signing a Country Compact, all partners agree that any support given is rallied around “one national health plan, one M&E [monitoring and evaluation] framework, and one review

each country’s ability to handle its health problems as the new aid requires separate plans, operations, and monitoring outside of the government’s own programs. As donors continue to earmark aid for their own priorities, countries are struggling to strengthen budgeting processes and expenditure activities.5 Until disease-specific programs are integrated into a country’s national health system, efforts to improve health will not be synergistic, cost effective or sustainable. Currently, aid money is not achieving as much as it could.6

The IHP+ addresses these issues by encouraging donor governments to stop funding programs that do not put their money through the recipient country’s planning and budgeting processes. It can also ensure more coordinated financing so that countries have more predictable funding to better invest in long-term plans.6 By increasing the coordination of aid, the


iHP+ • Agreement to coordinate funds through existing systems and policies

• No new funds • Donors accept national health plans for funding

• Governments agree to implement national health plans

• Funds from donors support national health plans

• Improve long-term financing commitments

• Donors and partners will adhere to commitments

table 1: Key elements of the iHP+ Reform

Gordon Brown at the World

Economic Forum Annual Meeting in

2008.World Economic Forum, 2008.


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ncommon goal. It has been suggested that health interventions are often duplications, not synergies, and as such, the funding of numerous health plans from numerous agencies is a confusing and ineffective use of resources.8 By coordinating many donors and international organizations and holding them responsible for accepting a single national health plan for each country, the IHP+ could establish control over actors and be seen as providing leadership. The IHP+, however, is non-binding. Due to the fact that there are no consequences for governments or international organizations who become members but do not follow the commitments set out in the Global Compact, it has proven difficult to ensure adherence.9

Furthermore, the necessary global health leadership should establish a clear

process,” in order to improve long-term financing commitments.7

The Global Compact outlines the following three commitments for all members: work together more efficiently to improve health outcomes; build on and use existing systems for the planning and delivery of health care; and be held accountable for implementing the compact.7

In particular, bilateral donors commit to accepting national health plans as the framework for funding, rather than developing independent plans. In response, recipient country governments commit to implementing these national health plans as a way to guide development through the use of existing resouces.7

The IHP+ itself does not provide any new funding.1 Rather, it is an opportunity for countries to better coordinate and allocate existing funds. While in the past it has been difficult to measure the effectiveness of aid at a country level, the commitments of the Global Compact encourage the development of outcome measures for evaluating health systems, allowing for results-based funding.1

evidence-informed Analysis of the Reform

1. the Lack of Global Health Leadership

One of the grand challenges in global health, as identified by Gostin and Mok, is the lack of global health leadership.8 Leadership is crucial for achieving success in global health because leaders can establish control over a large number of actors in order to unify goals and objectives. It is possible that the IHP+ could be seen as offering global health leadership, since it attempts to channel the actions of many towards a

A young girl receives a

vaccine as part of a vertical

UNICEF program.

Julien Harneis, 2009.


2. the need to Harness the creativity, energy and Resources for Global Health

The need to harness the creativity, energy and resources for global health is also a grand challenge in global health governance.8 The global health community needs to engage new actors in ways that are synergistic in order to improve global health outcomes. Part of harnessing the available energy includes facilitating non-state actors, and encouraging them to engage in health-benefiting activities, rather than harmful ones. The IHP+ harnesses this energy and creativity by acknowledging the role of civil society in developing national health plans, as well as the role of NGOs, other governments, parliamentarians and the private sector.2

Where the IHP+ falls short in this respect is its lack of incentives to promote adherence. Incentives, if provided to the

mission to improve world health and provide numerous actors with a single agenda.8 The IHP+ does not provide a global agenda for the improvement of world health. Rather, it acts only to coordinate initiatives already in existence. As well, an important leadership aspect of the IHP+ could be seen as its ability to conduct research on how best to measure the effects of health system strengthening.2 Since the IHP+ is not intended to provide any new funding, there are no resources in place to ensure that research is conducted in these areas. The ability to measure the effects of health system strengthening is an increasingly important research area for the future of global health, and technocratic leadership in this area would likely be sought by key players.1 Therefore, the failure of IHP+ to provide the resources to conduct research in this area could contribute to the loss of a potential leadership role in the global health arena.

A girl waits to be seen at an

orthopedic hospital in Rwanda.

Katryna Stemmler, 2009.


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nfor alignment and coordination.2 This would take a great burden off national governments and health ministries, since they are constantly faced with a wide range of international agencies from which to garner support and request funds. However, critics have increasingly seen the IHP+ act as a standalone project, whereby it actually increases the number of actors and adds to the number of barriers national governments face when implementing health plans.10

According to the 2009 Core Team Report, the IHP+ needs to focus on catalyzing changes in procedures and behaviour within organizations, not on new procedures or new organizations. As such, it is important that they work only through existing policies and staff, so as not to add to the number of new players. This is difficult since staff are already busy in their roles, and working through existing procedures does not allow for visibility of the IHP+. According to the report, if the IHP+ wants to be part of the solution, then it must develop new strategies to overcome this issue. By catalyzing change in existing procedures, and encouraging the alignment of national governments with development agencies, the IHP+ could increase coordination in the global health field. However, in order to do this, it must

right actors and stakeholders, could lead to well-funded solutions to improve global health.8 Unfortunately, the IHP+ does not offer such incentives and, as such, is having difficulty enforcing adherence. For example, the 2009 Core Team Report noted that developing countries were becoming frustrated at the slow pace of behaviour change from development partners. At the time the report was written, no bilateral donors or international organizations had fulfiled their Global Compact commitment to annually report on their progress, making it difficult to assess the effects of non-state actor involvement.10 Furthermore, while the partnership does engage non-state actors, it fails to sufficiently involve non-health sectors (e.g., food and transportation), which are important players for the promotion of health-conscious decision-making.

3. the Lack of collaboration and coordination Between Multiple Players

A third grand challenge in global health governance is the lack of collaboration and coordination between the ever expanding number of players, leading to fragmentation and duplication of health initiatives and funding.8 In theory, the IHP+ could be the ideal organization to address this need







iHP+ • Establishes control but fails to set an agenda for world health improvement

• Engages non-state actors, but does not offer incentives to encourage adherence

• Attempts to align donors, but needs to work through existing plans and procedures

• Aims to strengthen health systems but lacks information and evidence

• Tries to move away from vertical aid towards sustainable systemic aid

• Little atten-tion paid to these factors meaning there is minimal evidence of advancement

table 2: How the iHP+ Addresses Six Grand challenges in Global Health Governance


disease-specific initiatives) and non-partner actors (e.g., the United States). However, there have been some promising results in this area. PEPFAR, an existing disease-specific initiative, has pledged major financial support in line with these action agendas.3 As well, USAID has sent a letter of support to the IHP+, stating that the United States supports the principles on which it is based.2 It is possible that the IHP+ could step into the role of providing coordination, if incentives were put in place for more actors to become signatories.

While synchronization among multiple players would require the cooperation of all involved, it would be difficult, even imprudent, to provide mechanisms for coordination to which all actors were forced to adhere to, since not all would agree upon the decisions made. If coercion were used to establish coordination, then any player who wished to act autonomously would be doing so in opposition to enforced guidelines, and would therefore face consequences. This denial of authority could lead to animosity between players, where before there was simply confusion.

4. the neglect of Basic Survival needs and Health Systems Strengthening

Gostin and Mok identify the attainment of basic human needs through the development of scalable and sustainable health systems as another grand challenge in global health.8 The IHP+ clearly recognizes this challenge as a central goal to its Global Compact. The primary goal of the IHP+ is to target weak health systems by supporting developing countries in establishing health plans which reflect the needs of the citizens.3 The IHP+ proposes that this will be done by a donor-recipient commitment to jointly appraise

find other ways to deal with its lack of visibility and overworked staff.

In explaining the lack of coordination between players, Gostin and Mok point to the IHP+ as a potential solution to this problem.8 However, they raise concerns that the level of collaboration may not be sufficient, since it would be difficult to involve non-IHP+ initiatives (e.g., existing

A boy carried by his father in

Varanasi, India.Jake Hirsch-Allen, 2006.


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financing.12 If the IHP+ were to become a dominant player on the global health stage it could have the capacity to shift the focus of partners towards basic survival needs through its commitment to health systems strengthening.

Nevertheless, the partnership must first address several challenges if it is to become a leader in global change. Very little evidence of strengthening health systems in developing countries exists and, what little evidence there is, is not being communicated to those who would benefit from using it.9 Information sharing is crucial to achieving this goal and developing frameworks or strategies to implement changes on a global scale. Improvements need to be made in the channels via which partners communicate with each other to discuss successes, failures and experiences in terms of health strengthening endeavours worldwide. There is currently no forum in which partners can communicate their knowledge and where technical experts can share methods to approach health systems strengthening, including what considerations need to be made on an individual country basis.9

national health plans, jointly agree on how to finance health plans, and for the donor country to provide technical assistance.3 The IHP+ also emphasizes a need for long term predictable financing to ensure sustainability of the health system changes.2 However, issues such as complacency among donors or weak managerial capacity among recipient countries have been insufficiently recognized and addressed by the IHP+.10 The failure of the IHP+ to adequately prepare for these challenges may become a major barrier to progress.

Despite recognition of health systems strengthening as a primary aim of the partnership, there has been minimal evidence to demonstrate how partners are working toward this goal.11 Previous attempts at health systems strengthening have focused on the delivery of services without regard to other aspects which affect how well services are provided. These other aspects include resource generation and sustainability, effective management of the resources (such as optimizing the delivery of services), and a commitment to developing long-term frameworks and maintenance of

A woman selling vegetables by the street in Bangkok, Thailand. Jake Hirsch-Allen, 2006.


strengthen health systems by securing aligned predictable funding and creating health agendas which reflect the developing country’s interests.2 With a focus on health systems strengthening, the major challenge the IHP+ faces is the execution of this commitment.

Despite the agreements made by partners, the 2010 report issued by IHP+Results, an independent consortium responsible for compiling evaluations and monitoring reports, indicates that national plans are still trying to accommodate competing priorities based on donor funding and preferences.9 Some analysts have also recognized the potential for a shift in the balance of power away from the developing countries’ governments toward the group of donors.12 Additionally, IHP+Results has not published any specific evidence showing that the longer term commitments outlined in the Global Compact have improved health budgets in developing nations. The shift from a focus on medium-term health goals to those that are long-term has not yet occurred and, as a result, national health plans have not changed significantly to concentrate on long-term, preventative health development strategies.14

Before these goals can be realized, there needs to be a greater commitment by bilateral donors to follow through on their agreement in the Global Compact. Partially due to the fact that the IHP+ is a relatively new program, there have been few reports of how – or if – partners are working towards these goals. The underlying problem with achieving these aims is the lack of accountability on the part of the bilateral donors. With few incentives or consequences for non-compliance, the IHP+ fails to bring about the political willingness necessary to

5. the issue of Funding and Priority Setting

Funding for specific diseases or national security interests by a small number of wealthy donors tends to be favoured over larger, systemic endeavours which, according to Gostin and Mok, is a large problem in global health.8 This is known as the vertical approach to aid. Simply put, the vertical

approach is disease-oriented, whereas the horizontal approach is community-oriented and nationally driven.13 In the past, large organizations have focused their efforts on vertical programs that usually target infectious diseases. The result is that health infrastructures, disease control programs, and attention to non-infectious and less dramatic diseases has suffered.12 Additionally, Gostin and Mok state that stronger cooperation is needed between donor and recipient countries in developing health agendas.8 The IHP+ is in a position to directly address this grand challenge as it attempts to avoid the vertical approach of disease-specific interventions in favour of a broader systemic approach.6

One of the central commitments of IHP+ signatories is joint assessments wherein partner countries review the strengths and weaknesses of the national health strategies of developing partners. The purpose of these assessments is to

Local community

members learn about

reproductive health.

New Zealand Aid (NZAid), 2006.


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nmechanisms to rate the performance of signatories, it remains a major challenge.14

One concern is that the quality of the country-level commitments is variable, often lacking details regarding how commitments will be implemented and tracked and what measures exist to promote compliance and accountability.9 Additionally, the first IHP+Results ‘Interim Progress Report’ in February 2010 was critical of partners for neglecting their mutual accountability commitments and recommended they take greater responsibility in this area.14

shift national health strategies away from a strictly vertical approach.9

6. the need for Accountability, transparency, Monitoring, and evaluation

Gostin and Mok recognize accountability, transparency, monitoring and evaluation as being problematic and often disregarded in the global health world.8 Although IHP+Results is demanding more information from partners and has offered

A cigarette salesman in Manila, Philippines. Jake Hirsch-Allen, 2006.


area for improvement. Very little has been done by partners to transparently measure and review actions in implementing IHP+ commitments on a country level. Since 2007, no agency has publicly reported its performance in implementing commitments. As well, the signatories have not met their Global Compact pledge to meet annually and review progress towards fulfiling these commitments.14

The information provided by the partners has thus far been insufficient to determine how well the IHP+ is meeting its goals. The little evidence that does exist indicates that aid continues to reflect donor priorities and that there has been minimal advancement in health systems strengthening.11 The accountability of the IHP+ partners remains uncertain at the current time, and the level of transparency is lacking. These are two factors that require

Furthermore, most countries have yet to demonstrate how the resources available to them are being used to achieve health results (with the exception of vertical programs which either already existed or operate outside of government funding or control).9 As of May 2010, IHP+Results reported that most countries have not yet shown how available resources are being or will be used to achieve health results. Additionally, they identified a major gap in information sharing among partners.9 In the past, experiential information has been disregarded as unreliable or weak. However, the IHP+ recognizes the value in sharing this data to strengthen partnerships. The IHP+ aims to emphasize the importance of relaying experiential information and, by doing so, could improve health systems on an international level.14

IHP+Results has also identified monitoring and evaluation as a major

Street scene in Ho Chi Minh City, Vietnam.Steven J. Hoffman, 2009.


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nFeasibility and Practicality for implementation

That the IHP+ is at least sufficiently feasible has been demonstrated through its current existence and implementation. The partnership has managed to continue expanding, including 12 new members since April 2009, and hence there must be a certain level of attractiveness for actors to become signatories.10 There is certainly pressure in international settings to maintain a visible presence in order to uphold reputations, which is perhaps why becoming an IHP+ member is politically attractive. Economically, the IHP+ is not asking much of countries, considering it simply wishes to redress the allocation of funds and not solicit new money. However, this requires significant behavioural changes and revisions to long-standing procedures, something that takes significant willpower and engagement. Operationally, it is difficult to commit to the IHP+. At a review by partners in 2010, the commitment was considered innovative but onerous.9

other implications

One major aspect that the IHP+ has struggled to recognize is how coordination would occur with other non-IHP+ initiatives and non-partner actors. This is a factor that has the potential to interfere with the progress of the partnership and may undermine the commitments of the IHP+.8

urgent attention if the IHP+ hopes to grow or even maintain its existing membership.

No similar program exists upon which the IHP+ could model an effective monitoring and evaluation protocol, meaning that in order to be able to report changes, it must first develop a strategy to collect data and ensure transparency by partners.9 Once IHP+ develops an effective method of ensuring accountability, transparency, monitoring and evaluation, it will be in a better position to generate methods for developing evidence-informed policies.


Politically, funding single diseases or vertical interventions is attractive to donor governments because there are quick results and measurable returns. As evidence regarding the sustainability and cost effectiveness of these programs is disseminated, governments are beginning to realize that results-oriented aid that targets specific diseases discourages country involvement, ownership and priority setting.5 The IHP+ attempts to address these concerns by focusing on strengthening health systems and encouraging coordination between governments and organizations. As governments recognize the need for sustainable aid and the autonomy of developing country governments, the IHP+ could become very politically appealing.12


iHP+ • Signatories of Compact • Developed/ developing agencies and governments

• Establish monitoring systems • Accountability incentives • Communication

• Minimal • Manpower to operate/ monitor • No new funds

• Insufficient preparation • Knowledge/ information gaps • Commitment

• Non-partner agencies and governments • Vertical aid organizations

• Shifts in balance of power • Conflict • Health system collapse

table 3: implementation considerations for the iHP+ Reform


IHP+ may become less appealing to bilateral donors. Until this mentality changes, the longer it will take for the donors to see concrete results, and the less invested they will become in a long-term commitment to the partnership. As the IHP+ exists now, it acts as more of a standalone project than a catalyst for systemic change.5

conclusion

If the IHP+ were to become the international leader in global health governance, a number of grand challenges could be addressed. Firstly, donor aid could be better harmonized, leading to increased coordination among multiple players. Secondly, this aid could be focused on health system strengthening, thereby

Another implication of the IHP+ initiative that needs to be considered is that as it changes the manner in which aid is delivered to developing countries, there are likely to be changes in the behaviour of donor agencies and their interactions with developing countries. Questions are thereby raised regarding how to address additional resource commitments, as the need arises, and how this may influence the global donor-recipient dynamic. Currently, there is a sense that recipient countries are moving faster than their donor counterparts, leading to frustration and causing developing nations to question the commitment of the donors.10 The need for quick results is not a behaviour that can easily be changed, meaning that if significant results are not reported soon the

World leaders and other

participants stand together to ‘Call to Action on

the Millennium Development Goals’ at the

World Economic Forum Annual

Meeting in 2008.World Economic Forum,

2008.


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nshifting attention away from a strictly vertical approach. Thirdly, the transition of health system development to national governments could lead to increased national ownership and more sustainable systems. Currently, the IHP+ faces a number of barriers to addressing these challenges. Firstly, the lack of incentives for adherence to the Global Compact makes it difficult to ensure accountability. As well, the lack of involvement from non-members leads to difficulty establishing sufficient coordination mechanisms. Finally, the lack of monitoring and evaluation limits the progress of the partnership and stymies the ability of members to make evidence-informed decisions. While many shortcomings of the IHP+ have been addressed, the partnership is in its infancy and, in order to realize its goals, further changes are needed.

Key Messages

» The IHP+ can help address the challenge of coordination through the alignment of donor aid.

» The IHP+ could be fundamental for priority setting in the global health arena by focusing on country-led national health systems.

» Providing incentives for adherence to commitments could ensure increased accountability and political willingness among IHP+ partners.

» Developing effective monitoring and evaluation protocols for partners could allow for the development of evidence-informed policies.

» For the IHP+ to assume a more prominent role in global health governance, it would need to engage non-IHP+ initiatives and non-partner actors to increase coordination among multiple players and provide global health leadership.


References1 International Health Partnership: a welcome initiative. The Lancet 2007; 370: 801-801. 2 International Health Partnership and Related Initiatives. Welcome to the International Health Partnership and related

initiatives [Internet]. 2010 [cited 2010 Nov 18]. Available from: http://www.internationalhealthpartnership.net/en/home

3 Alexander D. The International Health Partnership. The Lancet 2007; 370: 803-804.4 Institute for Health Metrics and Evaluation. Financing Global Health 2010: Development Assistance and Country

Spending in Economic Uncertainty. Seattle (WA): IHME (US); 2010.5 Walker L. Global Health Initiatives (GHIs): Institutional Innovation and the Challenge to Development Evaluation

[PhD thesis]. Warwick (UK): The University of Warwick; 2009 Dec [cited 2010 Nov 18]. Available from: http://www2.warwick.ac.uk/fac/soc/csgr/research/workingpapers/2010/26310.pdf

6 England R. The Dangers of Disease Specific Programmes for Developing Countries. British Medical Journal 2007; 335: 565-565.

7 International Health Partnership and Related Initiatives. Becoming a partner: international and bilateral agencies. [Internet]. 2010 [cited 2010 Nov 18]. Available from: http://www.internationalhealthpartnership.net/CMS_files/documents/becoming_a_partner__development__EN.pdf

8 Gostin L, Mok E. Grand challenges in global health governance. British Medical Bulletin. 2009; 90: 7-18.9 IHP+ Results. World Health Assembly IHP+Results Update (May 2010) [Internet]. 2010 May [cited 2010 Nov 18].

Available from: http://network.human-scale.net/docs/DOC-2619 10 International Health Partnership and Related Initiatives. IHP+ Core Team Progress Report, for April 2009 – May

2010 [Internet]. 2010 [cited 2010 Nov 18]. Available from: http://www.internationalhealthpartnership.net/CMS_files/documents/ihp_core_team_report_april_2009m_EN.pdf

11 Labonte R, Marriott A. IHP+: little progress in accountability or just little progress? The Lancet 2010; 375: 1505-1507.

12 Murray CJ, Frenk J, Evans T. The Global Campaign for the Health MDGs: challenges, opportunities, and the imperative of shared learning. The Lancet 2007; 370: 1018-1020.

13 De Maeseneer J, Flinkenflögel M. Primary health care in Africa: do family physicians fit in? British Journal of General Practice 2010; 60: 286-292.

14 Conway S, Harmer A, Spicer N. 2008 External Review of the International Health Partnership + Related Initiatives [Internet]. Johannesburg: Responsible Action (South Africa); 2008 Aug [cited 2010 Nov 18]. Available from: http://www.internationalhealthpartnership.net/CMS_files/documents/ihp_external_review_2008_1_EN.pdf


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nAppendixMembers of the international Health Partnership

Low-income Partners1. Benin2. Burkina Faso3. Burundi4. Cambodia5. Cameroon6. Democratic Republic of Congo7. Djibouti8. Ethiopia9. Kenya10. Madagascar11. Mali12. Mauritania13. Mozambique14. Nepal15. Niger16. Nigeria17. Pakistan18. Rwanda19. Senegal20. Sierra Leone21. Togo22. Uganda23. Vietnam24. Zambia

Bilateral donors1. Australia2. Belgium3. Canada4. Finland5. France6. Germany7. Italy8. Norway9. Portugal10. Spain11. Sweden12. The Netherlands13. The United Kingdom

international organizations and Foundations1. Joint United Nations Programme on HIV/AIDS

(UNAIDS)2. United Nations Children’s Fund (UNICEF)3. World Bank4. United Nations Development Programme

(UNDP)5. United Nations Population Fund (UNFPA)6. World Health Organization (WHO)7. African Development Bank (AfDB)8. International Labour Organization (ILO)9. Bill and Melinda Gates Foundation10. European Commission11. GAVI Alliance12. Global Fund to fight AIDS, Tuberculosis and

Malaria

Source: International Health Partnership and Related Initiatives. Partners [Internet]. 2010 [cited 2010 Nov 18]. Available from: http://www.internationalhealthpartnership.net/en/partners.

G8 leaders saw this banner on their way to the Huntsville summit.World Vision Canada, 2010.

cHAPteR 4 GRouP oF 8 (G8)

By Narmeen Haider and Hun-Je Park


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nintroduction

A recent proposal for the reform of the Group of 8 (G8), which consists of the United States of America (U.S.A.), Canada, Russia, France, Germany, the United Kingdom (U.K.), Italy and Japan, recommends that it take on a more active leadership role in the global governance of health.1-2 Along with the eight countries in the G8, the European Union is also represented, though it cannot chair or host meetings. Many scholars have argued that the G8 should become more than a mere source of funding. They believe that the G8 should act to counter the inefficiencies of existing global health governance structures. This proposal calls for a greater financial and structural commitment from members of the G8 to implement and sustain health programs around the world.

Putting the Reform into Action

A tangible way to realize this proposal would be to hold an annual meeting for health ministers, shifting from a disease-specific to a health systems-based approach and including a broader range of countries, especially developing countries. This proposal argues that by implementing the aforementioned changes, the G8 will be better able to govern global health by setting priorities, making key decisions and directly coordinating health programs.3-4 This operationalization of the G8 reform will be evaluated in the remainder of this paper. This paper will critically analyze the strengths and weaknesses of the proposed reform and evaluate its feasibility.

Abstract

this paper will examine the proposed reform of the G8 to fill existing gaps in global health governance by holding annual meetings for health ministers, shifting from disease-specific to health systems approaches, and including a broader range of countries. Proponents of this proposal argue that it would present a strong leader in global health that is currently lacking. Structurally, the G8 is suitable to take on a leading role in the global scene and has precedence in assuming this role in other global issues. the financial resources and the political influence that the members of the G8 possess also may help implement this proposal. Many issues still remain, however, and whether non-member states would lend their political support to this proposal is questionable. Potential conflicts with existing global health organizations and high costs of summits are among other issues that must also be considered.

54 << Group of 8 (G8)

(i) the lack of global health leadership

Currently, the World Health Organization (WHO) has the mandate to be the world’s leader in global health. However, its lack of funding and political support has undermined its leadership capabilities.5 This proposal suggests the G8 is the logical candidate to take on the role of global health governance leadership due to its resources and political influence. The G8 collectively accounts for more than 65% of the world’s gross domestic product.3 This offers the G8 unparalleled political and financial power which it can use to advocate for initiatives at international forums.6 An example of this power was seen at the 2000 Okinawa summit where the then G7 finance ministers pushed for reform in the international financial system; most of the reforms proposed at the summit have been carried forward. Furthermore, the G8 has been

change versus Solution

Addressing challenges in global health governance

Gostin has identified six grand challenges of global health governance that represent broad issues that prevent global health justice for all.5 The challenges are: (i) lack of global health leadership; (ii) need to harness creativity, energy and resources for global health; (iii) need for collaboration and coordination of multiple players; (iv) neglect of basic survival needs and health systems strengthening; (v) lack of funding and priority setting; and (vi) need for accountability, transparency, monitoring and enforcement.5 An analysis of the proposal’s ability to address and overcome these challenges of global health is necessary before these changes can be further considered.

G8’s 30th Summit in

Sea Island, Georgia.

Taylor Davis, 2004.


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(ii) need to harness creativity, energy and resources for global health

The G8 already represents one of the largest sources of global aid and funding for health programs. For example, the G8 member states contributed US$8.1 billion to health programs in the developing world in 2002.9 Since then, their contribution has increased significantly, with more than US$35 billion committed by G8 member states after the 2005 Gleneagles summit.10 Given the large pool of resources it can draw from, the G8 may be a natural candidate to take on the role of global health governance as the proposal suggests.

However, bringing together eight influential countries to make conjoined decisions on global health governance could result in the loss of individual creativity.11

quick and efficient in decision-making due to its flexible agenda, as was the case in dealing with the conflict in the former Yugoslavia and the international terrorist threat.6 This authority can be used in the realm of health care as well.3,6

While the small decision-making body of the G8 has shown its ability to react quickly to pressing issues when there is a general consensus among its member states, it has also demonstrated that decisions are difficult to make should disagreement arise. For example, at the Gleneagles summit in 2005, the U.S.’s reluctance to commit to an agreement to reduce greenhouse gas emissions led to a failure to establish such goals. Instead, a text recognizing the importance of addressing environmental issues was published in its place, with no tangible plan of action.7 This is in direct contrast to other governing bodies such as the WHO, which makes decisions based on a democratic voting system at the World Health Assembly that requires a two-thirds majority of present voting members.8 The inability of the G8 to reconcile differences in opinion and take action even with the support of the majority of its members may hinder its leadership capabilities should the G8 become a larger player in the global governance of health.


G8 • Increase governing role and authority in global health

• Greater financial and resource commitment

• Health ministers’ summit • Fund and implement programs

• Immediate response to issues • Prioritizing of global issues

• Leadership in global health • Improved health systems

• Multi-stake-holder approach • Financial compliance

table 1: Key elements of the G8 Proposal

Secretary General Ban Ki-Moon makes the opening statement at the

Plenary of the World Health Assembly in Geneva, Switzerland in May 2009.

UN Photo/Eskinder Debebe, 2009.

56 << Group of 8 (G8)

environmental ministers to discuss and coordinate a collaborative course of action. Health ministers do not yet have their own annual summit. The G8 is also currently not mandated to address health issues. The Hokkaido Toyako summit in 2008 showed the advantages of holding a summit for health experts. Through this meeting they were able to draft the Toyako Framework for Action on Global Health, which outlines the actions that need to be taken on global health.3 Health experts can help identify issues that need attention and result in a higher contribution from the G8 on global health. This proposal recommends that not only health experts, but also health ministers, meet annually in order to add political support to global health issues through the influence of high government officials.4 A precedent for this has already been set in the 2001 G7 health ministers meeting in Ottawa.

The idea of bringing together health experts and officials from around the world to discuss and coordinate global issues is hardly an innovative concept in global health governance. The WHO, whose lack of strong leadership in the realm of global

Richter argues that with increased global emphasis on a partnership governance paradigm such as the G8 summits, in which decisions are made collectively by a group of different nations and actors, there is a loss of distinct aims and roles of each actor. He argues that this leads to comprimizing of individual ideas into a single outcome which lacks the creativity and diversity of each actor in the decision-making process. Furthermore, if this proposal were to be implemented, the ideas and beliefs of a small group of influential nations would translate into global action affecting the rest of the world. In this regard, existing organizations such as the WHO, with greater representation from more nations, may be better suited to make key decisions in global health.6

(iii) need for collaboration and coordination of multiple players

The proposal suggests that the G8 can foster collaboration and coordination by hosting regular summits for health ministers. Currently the G8 holds annual summit meetings for the heads of governments, finance ministers, foreign ministers, and

Oxfam campaigners dress as G8 leaders

with Pinocchio heads at the Port of Rostock, Germany,

where the G8 Alternative Summit

took place, to protest against the G8 leaders backing up on

promises made. Craig Owen, 2007.


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n(iv) neglect of basic survival needs and health systems strengthening

Like many other organizations, the G8 has primarily focused its resources on vertical, or disease-specific, programs rather than horizontal programs, which focus on health systems as a whole.13 The vertical approach to health has caused a lack of global attention to the development of sustainable health systems in developing nations, often undermining previous vertical efforts to address health issues. Buse and Waxman have described this focus on specific diseases in small areas as creating “islands of excellence in seas of under provision.14” Examples of past issues tackled by the G8 include HIV/AIDS, malaria and tuberculosis at the 2000 summit in Okinawa, the SARS outbreak at the 2003 summit in Evian, and the HIV/AIDS epidemic at multiple summits.15 According to this proposal, “it (the G8) should aim to drive change in entire health systems rather than make isolated pronouncements

governance of health has led many scholars to recommend increased global health leadership from the G8, holds an annual meeting of representatives from its 193 member nations to coordinate its course of action: the World Health Assembly. Despite these efforts to create a more collaborative plan of action in response to global health issues, the WHO has been criticized for its inabilities to act as a strong source of leadership in the 21st century.12 Whether the G8, with its political influence and resources, is able to better facilitate collaboration and coordination through a health ministers’ meeting of its few member states where a summit of 193 representatives has failed, remains to be seen.

G8 leaders at the G8 Summit in Huntsville, Ontario.

Foreign Affairs and International Trade Canada, 2010.

58 << Group of 8 (G8)

to identify and prioritize health issues that require global action. The proposed reform would bring together decision-makers from various nations, both member states and developing countries, to discuss and analyze pressing health issues. Donor countries often provide aid based on what they think taxpayers would be more willing to fund, whereas recipient countries are willing to take any funding for their expansive health care needs.17 This disparity in the views of donor and recipient countries has led to inefficiencies in health governance today. Through a collaborative discussion to determine how best to allocate resources and efforts between donor and recipient countries, this issue of inefficient priority setting can be addressed, resulting in greater advancements in global health.

Compliance with funding by the G8 following summits has been varied. While certain issues such as the SARS outbreak (78%), aging (67%) and biotechnology (66%) have had relatively high funding compliance rates, other issues such as polio (31%) and development (0%) have been severely underfunded.15 Existing leaders of global health governance, such as the WHO, that rely heavily on funding from member countries, have faced similar issues of non-compliance and underfunding. This lack of resources and compliance

on constantly shifting themes.4” The G8 has previously failed to address the need to improve health systems through training healthcare professionals, improving infrastructure, advancing technology and increasing access to care in developing nations.4 Under this new proposal, the G8 would aim to strengthen health systems while tackling disease-specific issues, resulting in a “diagonal” approach.13

But would a declaration and acknowledgement of the importance to strengthen health systems necessarily lead to action? Skeptics of such views point out that previous efforts to strengthen health systems in developing nations have yielded little change. For example, the WHO’s Ad Hoc Committee on Health Research highlighted the importance of strengthening health systems in its report in 1996. However, little has changed since its publication and many of the constraints that hinder the efforts of various health programs still exist today.16 It remains to be seen whether recognizing the importance of strong health systems will translate into tangible initiatives by the G8.

(v) Lack of funding and priority setting

The proposal argues that by holding an annual meeting of the health ministers of the member states, the G8 will be better able







G8 • Stronger leadership from politically and financially powerful member states

• Greatest source of financial resources in global aid

• Bring together health ministers and organizations to coordinate action

• Shift in focus from disease-specific programs to health systems strengthening

• Health summit to prioritize issues and catalyze compliance

• Ministerial re-commitment leading to “ratchet effect”

table 2: How the G8 could Address the Six Grand challenges in Global Health Governance


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input have been met with slow and low compliance.15 With the proposed reform, the G8 would take a more active role in prioritizing health issues and administering programs, potentially helping to catalyze compliance among members. However, such optimism must also be accompanied by caution, as such catalysts have already been utilized in the past with moderate success.

(vi) need for accountability, transparency, monitoring, and enforcement

The G8 has long been criticized for its lack of accountability, transparency and long-term sustainability. Member states are often not compliant with funding

has been a key causal factor in their inefficiencies.5 Assigning leadership to an organization which also relies on member state contributions and has a history of insufficient funding mechanisms may result in similar outcomes.

The G8 has previously used various compliance catalysts to encourage member states to contribute the funds and resources they promised. Prioritizing issues, designating agencies to carry out plans of action, and establishing a timeline have been highlighted by scholars to have been the most effective thus far.1 Looking to the G8 as simply a source of funds seems to have a negative effect on compliance, as previous initiatives with promises of quick resource

G8 leaders at the Huntsville Summit

discussing the outreach working

session. Foreign Affairs and International

Trade Canada, 2010.

60 << Group of 8 (G8)

among G8 nations. Furthermore, he points to the lack of enforcement mechanisms or compliance catalysts as a major cause for the low compliance observed in the past1. This proposal, while addressing many important aspects of global health governance, fails to account for these factors. Furthermore, unlike the WHO which has the authority to pass its legislations into global health law, the G8 does not have enforcement mechanisms other than providing financial incentives to compliant nations. The inability to enforce its resolutions in global health governance may present difficulties with the G8’s proposed role in global health governance.8

the G8’S influence and the World’s Reaction

The G6, the predecessor to the G8, was established in 1975 in an effort to collaboratively overcome the global financial crisis of the era and the effects of the Cold War.18 In the following decades, the aim and motivation of both the G8 and individual member states have broadened to other areas of global importance. Kirton asserts that for individual member states, the national pride and influence that comes with being part of an elite circle of global leaders in areas such as economics and trade, serves as incentives

promises and initiatives. For example, the G8 has had an average compliance rate of less than 46% in terms of funds raised for its various health initiatives.1 Many important health programs, such as the Polio Eradication Initiative which received only 11% of its promised funds, have been severely undermined.1 This proposal could potentially serve to improve compliance through ministerial re-commitment. Since 2002, the G8 Research Group at the University of Toronto has observed an increase in compliance rates among G8 member states. Kirton has attributed this increase in accountability partly to the first health ministers’ meeting held in 2001 in Ottawa. He argued that the re-commitment of health ministers to the issues addressed by heads of states created an internal “ratchet effect”, in which the echoing of commitments provided further support for initiatives.1

However, this proposal fails to address transparency and enforcement of commitments made by the G8. The G8 has been previously criticized for its lack of transparency.2 In his analysis of G8 compliance, Kirton argues that transparency of information leads to external pressures from third parties that catalyze compliance

Oxfam G8 campaigners

march in Germany on June 2, 2007.

James Maiden, 2007.


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nto other nations. Many critics point out that the G8, while controlling 65% of the world’s gross domestic output, represent only 13% of the world’s population.20 Different countries have different views due to their culture, customs and social norms, and a belief that a self-appointed group of nations can draft a universal solution may be naive. For example, despite past mandates by existing governing bodies such as the United Nations to uphold human rights, countries such as Nicaragua have failed to comply. A recent report highlighted Nicaragua’s lack of compliance in providing safe abortion for victims of sexual abuse as mandated by the United Nations’ Human Rights Working Group.2,21 The same may be true of the G8, where decisions made by a select few may not be supported by the rest of the world.

for them to continue to participate in summits.19 In this regard, taking a more active and direct leadership role in global health governance will be politically favourable for member states of the G8. The G8 has committed itself to “make globalization work for all [their] citizens and especially the world’s poor”, and increasing its role as a leader in global health will serve to support this goal.

However, the issue remains that non-member states, often developing nations to which the policies are primarily targeted, are under-represented at these summits. It is difficult to gauge how much political support the G8 will gather from non-member states with limited representation at the decision-making level. Decisions made at the G8 may not necessarily be applicable

Thousands of demonstrators march in downtown Toronto to protest

the G20 Toronto Summit.Eduardo Milano, 2010.

62 << Group of 8 (G8)

Along with member states of the G8, the G20 includes Argentina, Australia, Brazil, China, India, Indonesia, Mexico, Saudi Arabia, South Africa, South Korea and Turkey. Although it has yet to directly address health issues, the G20 presents a new opportunity for the global governance of health, in that it possesses both the resources and influence of the G8 with greater representation from other nations. However, under-representation of developing countries continues to be an issue, with South Africa being the only representative from Africa, and many parts of South and

Whether resistance from the rest of the world may hinder the G8’s emergence as a global health leader remains questionable, however, the political influence and resources of the G8 have granted them such powers in the past on other issues such as economics and the environment.

This proposed reform recommends that the G8 expand its dialogue to increase representation from the developing world to counter the issue of under-representation. The G8 has already taken steps to realize this aim, most notably through the establishment of the Group of 20 (G20).

King Abdallah bin Abdulaziz al

Saud of Saudi Arabia was invited

to attend the G8 Summits in

Huntsville, Ontario and stayed to

attend the G20 Summit in Toronto

as well.Foreign Affairs and International

Trade Canada, 2010.


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nproposed shift to prioritizing long-term healthcare system strengthening may not be politically feasible.17

Applying the Proposal

The lack of an effective global health governing body has set the stage for the G8 to fill this gap. The WHO has been previously mandated to take on this role, but its lack of initiative has led this proposal to call for greater leadership from the G8.23

Composed of the world’s most powerful leaders, the G8 can ease into the role of governors of global health.23 The members of the G8 serve as the world’s greatest source of foreign aid. The U.S. and the U.K. are the two greatest donating nations, with the U.S. providing more than US$4.19 billion annually to developing nations in direct aid.24 While much of this aid has been used to tackle health-related issues identified at every summit since 1999, the G8 was first established as, and still is, primarily an international economic forum. This provides the G8 with the opportunity to take action on health-related topics with economic and development perspectives through means such as development assistance, debt relief and trade liberalization.25 The void in global health governance leadership along with the G8’s abundant financial resources makes the implementation of this proposal both possible and likely.

Central America still being excluded from the decision-making process. Despite the advantages the G20 has over the G8, the global political reception to yet another self-appointed group of leaders remains questionable.3,22

The past 20 years have seen a dramatic increase in the interest in global health. From 1990 to 2004 there was a $10-billion increase in donations for global health assistance.9 Despite this increase in donations, global health continues to be in a dire state. The world’s poorest countries, such as African nations, have seen a 10-to-20-year decline in life expectancy in the past 25 years.9 Without improvement in the architecture of global health governance, this decline may continue. Recipient countries will benefit the most from constant aid focused on long-term improvement. This proposal suggests that taking on a horizontal approach to global health instead of a vertical approach will help strengthen entire health systems in a country, resulting in better health care. Schieber argues that this may not be possible due to the discrepancies between donor and recipient countries. While recipient countries are willing to accept any aid that comes their way, donor countries are more likely to aid causes with immediate results that can be reported back to their taxpayers. In a generation of instant gratification, taxpayers are more likely to fund immediate disease-specific programs instead of long-term improvements. The


iHP+ • Member states • Other countries • Existing agencies

• Initiative • Political support • Increased funding and compliance

• Summit • Financial obligation • Increased ministers’ duties

• Non- compliance • Conflicting national and global interests

• Underrepre-sentation • Shift in leadership-WHO

• Inability to act without consensus • Impractical programs for others

table 3: implementation considerations for the G8 Proposal

64 << Group of 8 (G8)

countries. With the proposed reform for greater initiative from the G8 countries in global health governance and a mandated health ministers’ meeting, the costs of the summits could increase. Critics of conference diplomacy question the cost-effectiveness of holding summits, asserting that these resources would be better spent on initiatives, rather than on holding more meetings.28

There would be few, if any, operational barriers to implementing this proposed reform. The G8 already holds annual summits for heads of states and ministers. Although currently not mandated, there is a precedence for meetings of health ministers to address health issues, beginning at the 2006 summit in St.Petersburg.3,23

However, social barriers may arise, since many developing countries may be hesitant to hand over such great authority to only a few nations.20 Also as mentioned before, while the G8 has an abundance of financial resources, its compliance rate with its own initiatives has been below target. Average compliance rate of G8 member states is only 45%.23 Increasing their role as a governing body may not guarantee an increase in funds. In this situation, the G8 would simply replace the WHO without remedying the existing problems of underfunding and lack of authority.5

other implications of the Proposal

The G8 and the WHO have worked collaboratively in the past to tackle some of the most pressing issues in global health today. The most noteworthy product of such collaborative efforts has been the establishment of the Global Fund. The Global Fund was the product of a multi-stakeholder dialogue held with contributions

The G8’s role as a global health governor is also structurally feasible since the G8 has already taken on the role of leadership in other areas, such as tackling global economic and environmental issues. The G8 has shown its willingness to be a vocal and active leader in tackling pressing issues, such as its role in the Kobe Initiative to reduce the global impact of greenhouse gases.26 Similarly, the Global Fund to Fight AIDS, Tuberculosis and Malaria, established in 2001, was part of the G8’s efforts to take on a more administrative role in the global governance of health, rather than merely acting as a source of funding for programs run by other organizations. In keeping with this new approach to be more directly involved in health programs, the G8 established the Health Action Plan in 2003 to tackle the world’s most pressing health issues. Subsequent summits have yielded similar short-term initiatives, with the Global Fund thought by many to be the most successful. The successes of the Global Fund suggest that the G8 is capable of taking on the role of global health governance leadership.27

The proposed expansion of the G8 summits to include a health ministers’ meeting and to include more nations has been called into question for its practicality. There has been much debate over whether the costs associated with holding G8 summits are justifiable. Bringing together government officials of the most powerful and influential nations in the world brings with it necessary investments in security, accommodation and infrastructure. The total cost for the G8/G20 meetings held in Muskoka/Toronto in 2010 was in excess of $857 million.30 This figure only accounts for the cost to the Canadian government in hosting the summits, and does not include costs incurred by attending


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nindividual national interests. In his analysis, Bayne points out the reconciliation of domestic and international pressures as one of the challenges facing leaders of the G8.29 With conflicting national and global interests, the leaders of the G8 are faced with a difficult task. Furthermore, the leaders of the G8 have been previously accused of using the G8 summits to promote their own domestic agendas, such as former U.S. President Bill Clinton’s use of the 1997 Denver summit to further his foreign policy on Africa.29 The proneness of the G8 to be heavily influenced by individual or national interests makes it an unlikely source of objective leadership in global health governance.

from the G8, United Nations entities such as the WHO, and non-governmental organizations that recognized the importance of tackling malaria, tuberculosis and HIV/AIDS.13 Could such collaborative efforts continue to take place with the proposed reform of the G8 as an emerging leader in global health governance? In their analysis, Chand et al. argue that the increasing role of the G8 in global health governance may act to undermine the efforts of existing organizations such as the WHO.10 Without a clear distinction in the roles of the different actors in global health governance, the resources and efforts of these actors may not be efficiently allocated.

Unlike existing global organizations such as the WHO, the G8 is made up of a small number of member states with

G8 leaders convene in Huntsville, Ontario on June 25, 2010.

The Prime Minister’s Office, 2010.

66 << Group of 8 (G8)

conclusion

This proposed reform for the G8 to take an active leadership role in the global governance of health presents both strengths and weaknesses that have been explored in this paper. Operationalization of this proposal through health ministers’ meetings, increased representation of nations at summits, and prioritization of developing health systems appear feasible. However, the continued lack of representation from the developing world, high costs of summit meetings, and the conflict between global and national interests threaten the political attractiveness of this proposal. Whether these challenges can be overcome will determine the future role of the G8 in the global governance of health.

Key Messages

» In order to reduce existing deficiencies in global health governance, the G8 must take on a greater role.

» This can be done by holding an annual meeting for health ministers, shifting from a disease-specific to a health systems based approach, and including a broader range of countries.

» The financial and political powers held by G8 nations and a lack of structural barriers make this reform plausible.

» The G8 has shown a willingness to take on a leading role in the governance of other global issues such as pollution and the economy.

» Many issues still remain despite the proposed reform, such as a lack of support from non-member states and the private sector.


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nReferences1 Kirton, JJ, Mannell J. The G8 and Global Health Governance. In: Cooper AF, Kirton JJ, Schrecker T. Governing

Global Health: Challenge, response, innovation. Ashgate Publishing 2007;115-146.2 Ullrich H. Global health governance and multi-level policy coherence: can the G8 provide a cure? Working Paper No.

25, Centre for International Governance Innovation, Ontario, Canada, 2008.3 Macdonald R, Horton R. Global health and the G8-is power just too sweet to share? The Lancet. 372(9633);2008:99-

1004 Attaran A, Hebert PC, Stanbrook M. Misplaced health expectations at the G8 summit. Canadian Medical

Association Journal. 2010;182(10):E426.5 Gostin LO, Mok EA. Grand challenges in global health governance. British Medical Bulletin. 2009;90:7-18.6 Weiss M. A. The Group of 8 Summits: Evolutions and Possible Reform. CRS Report for Congress. 17 March 2006.7 Peichert H, Meyer-Ohlendorf N (2008), G8 Impact on International Climate Change Negotiations – Good or Bad?

Ecologic Institute, Berlin.8 World Health Organization (1946), Constitution of the World Health Organization. World Health Organization,

Geneva.9 Labonete R, Schreker T. A global health equity agenda for the G8 summit. British Medical Journal. 2005, 330: 7490. 10 Chand S, Morrison S, Piot P, Heymann D. From G8 to G20, is health next in line? The Lancet. 23 June 2010. 11 Richter J. Public-private Partnerships for Health: A trend with no alternatives? Development. 2004. 47: 43-48.12 Ruger J. Global Functions at the World Health Organization. British Medical Journal. 2005. 330: 1099.13 Ooms G, Van Damme W, Baker BK, Zeitz P, Schrecker T. The ‘diagonal’ approach to Global Fund financing: a cure

for the broader malaise of health systems? Globalization and Health. 2008;4:6-13.14 Buse K, Waxman A. Public-Private Partneships: a Strategy for WHO. Bulletin of the World Health Organization.

2001,79:748-75415 Kirton, JJ, Kokotsis E. Keeping faith with Africa’s health: catalyzing G8 compliance. In: Cooper AF, Kirton JJ,

Schrecker T. Governing Global Health: Challenge, response, innovation. Ashgate Publishing 2007;157-180.16 Travis P, Bennett S, Haines A, Pang T, Bhutta Z, Hyder AA, et al. Overcoming health-systems constraints to achieve

the Millennium Development Goals. The Lancet. 2004 Sep; 364(9437):900-906.17 Schieber G, Fleisher L, Gottret P. Getting real on health financing – Will all hype and money lead to results? Finance

and Development. 2006 Dec;43(4).18 Lee S, Silver, A. The group of eight (G8) industrialized nations. Council on Foreign Relations (Online

communication, at http://www.cfr.org/publication/10647/group_of_eight_g8_industrialized_nations.html)19 Kirton JJ. A Summit of Pride and Influence? Canada and the Gleneagles G8. Munk Centre Monitor. Summer 2005.20 Reich M, Takemi K. G8 and Strengthening of Health Systems: Follow-Up to the Toyako Summit. The Lancet.

2009;373:508-15.21 Boseley S. Nicaragua refuses to life abortion ban. The Guardian, 11 June 2010.22 Editorial. G8-G20: Standing at a Crossroads. The Lancet. 2010;376(9735):70.23 Kirton JJ, Roudev N, Sunderland L. Making G8 Leaders Deliver: An Analysis of Compliance and Health

Commitments, 1996-2006. Bulletin of the World Health Organization. 2007;85(3):192-199.24 McCoy D, Chand S, Sridhar D. Global health funding: how much, where it comes from and where it goes. Health

Policy and Planning. 2009;24(6):407-417.25 Labonte R, Schrecker T. Foreign policy matters: a normative view of the G8 and population health. Bull World

Health Organ. 2007;85(3):185-191.26 3 Themes. Kobe, Kobe Environment Ministers Meeting 2008, 2008 (Internet communication, at http://www.env.

go.jp/earth/g8/en/meeting/index.html)27 McCarthy M. The Global Fund: 5 years on. The Lancet. 2007 Jul;370(9584):307-308.28 Kirkup J. Why critics believe the cost of G8 outweighs its value. The Scotsman, 07 June 2007.29 Bayne N. Decision Making in the G7/G8 System. Working Paper. London School of Economics and Political

Science, 2001.30 CTV News. Ottawa releases costs for G20, G8 summits. 2010. (Internet communication, at http://toronto.ctv.ca/

servlet/an/local/CTVNews/20101105/g20-costs-101105/20101105/?hub=TorontoNewHome)

A boat driver in Halong Bay, Vietnam. Jake Hirsch-Allen, 2010.

cHAPteR 5 GLoBAL HeALtH Fund

By Lauren Daley


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nintroduction

One proposed reform to global health governance is to expand the Global Fund to Fight AIDS, Tuberculosis, and Malaria into a “Global Health Fund” with the intention of directing funds to all health-related Millennium Development Goals (MDGs).1 If adopted, this proposal would represent a shift away from vertical funding by expanding the existing initiatives of the Global Fund beyond the three specific diseases it has focused on historically. The motivation for such a proposal stems from the recognition that the existing Global Fund does not address the primary concern of weak health systems in low- and middle-income countries that contribute to poor global health outcomes. The reform aims to tackle the lack of progress with respect to the health-related MDGs by recognizing the need for increased funding and more efficient spending if progress is to be made towards the development goals. This suggests a need for a restructuring of the current global aid architecture to ensure funds can be used in a way that is more effective at meeting the needs of the world’s poorest and most vulnerable.1, 2

The Global Fund to Fight AIDS, Tuberculosis, and Malaria was founded in 2002. Said to be the most successful innovation in foreign aid of the past decade, the existing Global Fund was designed to specifically target MDG6, and it is estimated that its programs have saved five million lives.3 The Global Fund’s operational procedures are given much of the credit for its overwhelming success. It is a country-led, performance-based model in which disease-specific committees in each developing country facilitate collaboration between national governments and non-governmental organizations to devise

Abstract

one proposed reform to global health governance is to expand the Global Fund to Fight AidS, tuberculosis, and Malaria into a “Global Health Fund” with the intention of directing funds to all health-related Millennium development Goals (MdGs). of the grand challenges to global health, this proposal responds to the need to harness creativity, enhance coordination among stakeholders, boost efforts towards health systems strengthening, improve priority setting, and ensure transparency and accountability. the proposal plays a less prominent role in addressing the lack of global health leadership, and also works to exacerbate the Global Fund’s current need for more funding. An advantage to this proposal is that it is not introducing a novel initiative, but rather an expansion of an existing initiative to address a broader scope of global health issues. A key factor impeding potential success of the proposal to expand the existing Global Fund is a lack of financial resources.

70 << Global Health Fund

and other resources in only a few specialized areas.5 This proposal addresses the more recently recognized need to shift away from vertical funding strategies to more comprehensive mechanisms of global health finance by addressing the broad spectrum of global health issues and acknowledging all health-related MDGs.1, 2

The reformed Global Fund must sustain current successful programs related to HIV/AIDS, tuberculosis and malaria, and expand on such initiatives by extending proven principles of aid effectiveness to other health needs and general health systems strengthening.1, 2, 3 The goal is that eventually the delivery of prevention and treatment for all relevant diseases will be accomplished through revamped general health services. A key component of this endeavour is to extend the Global Fund’s existing aid architecture to provide increased support to national health plans, which involves co-financing non-disease-specific human resources for health.4, 5, 6

Substantial increases in resources would be necessary to support the expansion of the Global Fund. Following the third replenishment conference in October

countrywide plans that are submitted to the Global Fund for approval.4 The Global Fund has a number of mechanisms in place to ensure each plan is feasible, according to available evidence. Once implemented, countrywide plans are subject to continuous monitoring and evaluation.4

While the vertical funding strategy adopted by the Global Fund has been successful in making progress toward MDG6, funding towards other health needs, including health systems strengthening, have not experienced the necessary progress.4 If approved, this proposal will attempt to address this concern by adopting a more comprehensive and coordinated funding strategy that is less disease-specific and provides an increased opportunity for health systems strengthening at the country level.4 The ultimate goal is to achieve progress towards all health-related MDGs.

Development assistance for health has been historically rooted in the notion that nations receiving assistance should eventually gain autonomy and finance health with domestic funds rather than international aid. However, with the injustices and inequalities that became so apparent in light of the AIDS pandemic, this traditional model of development assistance has been ignored. Rather than focusing on sustainable solutions to enhancing health systems capacity in the developing world, the focus shifted towards a rapid scale up of AIDS treatment and prevention.5 This approach was founded on the assumption that health systems were alive and well in the developing world, when in fact most are struggling to survive. A common argument is that the disease-specific focus endorsed by the current Global Fund further weakens health systems by concentrating limited governance, finances, information systems

A need for health systems strengthening: makeshift tent

hospital treats patients in need of medical care outside Leogane, Haiti.

Cory Rose, 2007.


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nThis, however, does not address the widely recognized and accepted need for a more overarching global governance structure with strongly fixed guidelines and binding regulations.10

2. the need to harness the creativity, energy and resources for global health

A key feature of the Global Fund is that it unites a large number of stakeholders, all bringing something of value to the table.1, 3,

5 The Global Fund engages an international board that includes representatives from donor and recipient governments, non-governmental organizations, the private sector and affected communities.11 Other key players who participate in the Global Fund’s International Board include the World Health Organization, the Joint United Nations Program on HIV/AIDS, various public-private partnerships, and the World Bank. The Board is the overall governing body of the organization and meets twice annually to exercise the powers of the foundation, which includes the approval of grants.12 In addition, the board upholds a commitment to reaching consensus when it comes to decision-making processes, which is grounded in the Fund’s vision to establish and maintain strong partnerships in a variety of contexts.11,

12 With such a breadth of diversity contributing to clearly defined goals, this

2010, it is estimated that the Global Fund continues to endure a shortage of US$ 2.9 billion through the next three rounds of funding.7 If sufficient resources and funding are not available to support the Global Fund’s mandate, there is serious potential for diminished progress towards achieving MDG6. Should the proposal be implemented without an increase in funding, there is even the possibility that the notable advancements made by the Global Fund could be reversed.2, 8, 9

evidence-informed Analysis

1. the lack of global health leadership

The proposed reform to the Global Fund does not explicitly address the issue of a lack of global health leadership, which is currently a grand challenge for global health governance. The proposed Global Health Fund would remain a funding agency for country-driven initiatives, and not become a global governance body. The reform offers a decentralized approach to funding development assistance. By expanding the Global Fund’s mandate beyond three specific diseases, governments of recipient nations will have to take on a greater leadership role when it comes to funding allocation and efficient improvement of health systems.


Global Health Fund

• To expand the Global Fund to address all health-related MDGs

• US$12 billion/yr over 3 years • Donor / recipient compliance

• Better access to health services • Needs of state better addressed

• Increased funding based on need, not disease

• Self- sustaining health systems

• Prolonged commitment from donors • New funding strategies

table 1: Key elements of the Global Health Fund Proposal


Bill Gates, founder of the Bill & Melinda Gates Foundation, a major donor to the Global Fund, speaks at the XVIII International AIDS Conference in Vienna, Austria.

Lauren Daley, 2010.


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nthe ground, and overall weaker national health systems.5 The proposed reform recognizes the need for an improved global health aid architecture that focuses on streamlining resources towards more effective and comprehensive initiatives addressing the health-related MDGs in general.1, 2, 5 A major advantage of this proposal is that it is not suggesting a new initiative, just an expansion of an existing initiative in an attempt to explore a broader scope of health issues. Employing the existing infrastructure of the Global Fund to support a new Global Health Fund means that aside from increased funding commitments, few additional resources would be required to actually implement this proposal.4, 9

The current global health landscape is complicated. An increasing number of problems and players at work has allowed for a growing number of health issues on diplomatic agendas, resulting in many diverse diplomatic processes addressing global health.15 As such, a major challenge of global health lies in the effective coordination of responses to global health issues.15 There is potential for the introduction of this proposal to cause fragmentation and incongruence among the many actors and stakeholders contributing to the existing Global Fund. Should these key players disagree with the new mandate of the proposed reform, it could limit the momentum towards achieving the health-related MDGs, including MDG 6.13, 15

The importance of effective collaboration is exemplified in the action that would have to be taken by the International Monetary Fund (IMF) in order for this reform to be as effective as possible. The IMF’s restrictive policies and deficit and inflation targets in their

proposal has the potential to capitalize on the creativity, energy and resources of the many stakeholders involved in the existing Global Fund’s multilateral approach to funding global health initiatives.

That being said, the proposed reform would require tremendous intervention and restructuring of the current Global Fund, which will undoubtedly have repercussions for the many stakeholders who commit to donating huge amounts of money to the Fund. Such a shift with respect to how funds are allocated in recipient countries may cause donors to hesitate before initiating or renewing financial commitments.9

The proposal would undoubtedly have a tremendous impact on the momentum behind creative ideas, and new and expanding programs, but only if the money becomes available to support such initiatives. More money presumably means more action, as was demonstrated in the so-called “Global Health Revolution” of the past decade, which has come to an apparent standstill in recent years due to the economic downturn.13

Furthermore, incredibly innovative approaches to funding are already in place with the Global Fund, and the expanded fund would presumably continue to capitalize on new and improved creative funding initiatives.14 For example, the Global Fund is currently the beneficiary of Product Red, which is one of the most successful and innovative cause-related marketing ventures in existence.14

3. the lack of collaboration and coordination between multiple players

Evidence suggests that vertical funding can contribute to the fragmentation of aid, leading to reduced donor coordination on


that both disease-specific funding as well as health system strengthening are necessary approaches that should operate parallel to one another. This raises a key question: Can the Global Fund engage in health systems strengthening without compromising its original commitment to MDG 6?9

Skeptics of the proposal question how much of a difference expanding the mandate of the Global Fund will make. Their argument is that the Global Fund is already contributing significantly to health systems, with at least 30 per cent of the Global Fund’s financing in rounds one through seven being focused on health systems inputs.8, 9 Although funding provided by the Global Fund must lead to improved outcomes related to MDG 6, if money happens to be invested in health systems through programs funded by the Global Fund, it is never restricted to fighting just those three specific diseases.9 As such, critics express concern that the costs to expand the mandate of the current Global Fund would not have a significant impact on overall outcomes as compared to the status quo. These concerns cannot be addressed without first acknowledging the issue of money.

loans are a major impediment to countries trying to raise more of their own resources domestically. In order for recipient countries to benefit from development assistance in a way that is conducive to health systems strengthening at the country level, the IMF should loosen its policies so as to not eclipse the intended outcomes of the proposed expansion of the Global Fund.16 In this regard, a very powerful institution will have to alter its strategies in order to effectively coordinate with the goals of a Global Health Fund. Failure to do so would limit the potential impact of this proposal.16

4. the neglect of basic survival needs and health systems strengthening

In terms of supporting health systems strengthening, a shift away from vertical funding is expected to facilitate an increase in health capacities of low- and middle-income countries.1, 2 All the same, the proposed Global Health Fund would have to simultaneously continue fulfiling their commitments towards alleviating the burden of specific diseases, such as HIV/AIDS, tuberculosis, malaria, and other diseases that are limiting the progress towards the health-related MDGs.4 Jeffrey Sachs, a major proponent of this proposal, has expressed







Global Health Fund

• Would increase the leadership role & autonomy of recipient countries.

• Must capitalize on existing, inno-vative funding mechanisms.

• A shift from vertical fund-ing enhances coordination & collaboration.

• Both disease specific fund-ing and health systems strengthening are necessary.

• Financial resources to fund this proposal are presently unavailable

• Current evaluative practices of the Global Fund would remain

table 2: How the Global Health Fund Proposal Addresses Six Grand challenges in Global Health Governance


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nbeen seen in recent years, it remains below the level of funding necessary to implement this proposal. Regardless, this recent meeting is somewhat optimistic in that it demonstrates countries’ interest in funding global health despite the recent economic downturn.8

In general, the reform does not offer a clear-cut solution for the current lack of funding. In fact, it raises more concerns about how to increase financial commitments from donor countries to make the necessary changes to the Global Fund’s mandate. That said, the improvement of health systems is argued to be a long-term approach to sustainability, with the potential to offer lasting solutions to global health issues.5, 8, 10

Furthermore, a new Global Health Fund towards all health-related MDGs would lend itself to improved priority setting in the global health sphere, as it would be in a position to grant significant funds to health initiatives in participating low- and

5. the issue of funding and priority setting

One of the major frustrations faced by the Global Fund on a regular basis is a lack of financial commitment from donor countries. In particular, some rich countries continually fail to offer the funding they have the capacity to commit. This frustration would remain even if the proposed reform were to be adopted.

The Global Fund is already in a state of fiscal crisis.7 To meet the needs of expanding programs for the three diseases it currently funds, Sachs estimates an approximate need of $12 billion per year in the next three years.4 While Sachs argues that this is achievable, as it only constitutes three cents per $100 of the donor countries’ GNP, at the recent Global Fund replenishment conference in October, donors only committed a total of US$11.7 billion over the next three years.4, 17 Although this collective pledge represents a surprising increase in donor commitment than has

Mothers wait at a hospital in Northern

Uganda with their children, mostly under the age of

5 and sick with malaria.

Toshihiro Horii, 2003.


about $0.37 to health budgets in recipient countries.5 That being said the current Global Fund does what it can to ensure transparency and accountability, which are key features of all programs it supports. If the current operational procedures of the Global Fund are kept consistent with the expansion to the Global Health Fund’s mandate, then it can be assumed that continual auditing, monitoring and evaluation will take place to ensure accountability.5 Also, the vast number of stakeholders involved will continue to help ensure transparency and accountability with respect to how the Global Fund is governed. As long as these key stakeholders remain committed to the Global Fund in spite of an expanded mandate, this should continue.

Feasibility considerations

The issue of HIV/AIDS alone has already generated a tremendous amount of political interest and funding.15 Yet the current state of global health has caused many to

middle-income countries. With available funds comes the ability to set priorities and streamline resources in a way that is efficient and conducive to achieving progress.11 Because a new Global Health Fund would presumably employ the operational procedures of the existing Global Fund, current mechanisms of the Global Fund that enable effective priority setting would remain. For example, country coordinated mechanisms in place to assist in the development of proposals based on priority needs at the national level would continue to play a role in appropriate priority setting, should this proposal be implemented.11

6. the need for accountability, transparency, monitoring and evaluation

Evidence suggests that much aid is not reaching the poor. This is not only due to corruption at the country level, but also to diversion of aid for purposes other than improving health and well-being. Studies show that each $1 of health aid adds only

Jeffrey Sachs, an influential American economist and

one of the world’s leading experts on sustainable development, is also a

proponent for the proposed reform to the Global Fund.

Maureen Lynch, UNDP, 2009.


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ninstitutions are contributing to a single funding body. While the existing Global Fund has enjoyed tremendous success within the current mandate, a shift in scope could seriously affect countries’ willingness to contribute in the future.13 Additionally, the global health landscape is becoming increasingly multi-polar with the onset of emerging economies and super powers. Global health reforms will become more difficult as these emerging powers push to have their interests reflected when it comes to decisions made regarding global health funding.10, 13, 15

Finally, the apparent need to achieve long-term, sustainable global health solutions, such as strengthening health systems, continues to be eclipsed by issues that present on the global agenda with more perceived urgency. Such issues include the global economic crisis, energy crisis, food insecurity crisis, climate change crisis, and other persistent global challenges. The pressing nature of these challenges often diminishes the perceived importance of global health governance concerns, making reforms to the existing global health architecture less of a priority.13

recognize that vertical funding may no longer be the answer to achieving maximum progress towards the health-related MDGs.10 This shift in ideology has become widely acknowledged, and the push to strengthen health systems in developing countries could capture widespread political support.

Conversely, governments need to demonstrate that their efforts achieve the intended results in order to remain accountable. Vertical funding is an easy way for both donor and recipient governments to demonstrate progress to the international community. Funding health systems is a more long-term goal that, to the public, appears to have less impact, because measuring and reporting progress becomes more abstract and less explicit.15

It has been suggested that the prospects for new overarching reforms to global health architecture are unlikely, given this current “latency” period after the global health revolution of the past decade.15 This threatens the prospects of implementing not only this proposal, but all global health-related reforms. Factors contributing to such resistance to reform include powerful states’ and stakeholders’ unwillingness to restrict their freedom of action.13 This becomes particularly true when dealing with an institution like the Global Fund, where so many donor countries and private


Global Health Fund

• Donor governments • Recipient governments • Private donors

• Increased donor commitment • Better funding strategies

• Increased human resource investment • US$36 billion/3 yrs

• Money gets rerouted to non-health- related causes

• Potential need for increased global public finance (i.e. global taxes)

• Reversal of progress made towards MDG 6

table 3: implementation considerations for the Global Health Fund Proposal


to be an adequate step towards achieving progress towards all health-related MDGs, the availability of financial resources remains the most important factor in determining the acceptance of this proposal. Unless there are drastic changes and broad acceptance of new sources of development funding, particularly global public finance, then the financial resources simply will not be available to support this proposal.10, 13, 16

conclusion

In a sense, the proposed reform offers a compromise; it acknowledges a need to support health systems strengthening in low- and middle-income countries, while remaining committed to funding specific diseases as outlined in the Global Fund’s original mandate.1 It cannot be ignored that the proposal to expand upon the existing Global Fund to address a broader scope of global health issues is very advantageous, as implementation of a new Global Health Fund can employ the existing infrastructure and effective operational procedures of an already well established institution.1, 2, 3

The present state of global health in light of the current political and economic climate will have a definite impact on the acceptance of this reform. While establishing a Global Health Fund appears

Key Messages

» The proposed expansion of the Global Fund could work to increase necessary progress towards all health-related Millennium Development Goals by focusing on more comprehensive funding strategies with the intention of strengthening health systems.

» Donor countries must be prepared to substantially increase their financial commitments in order to sustain the Global Fund’s new mandate as outlined in this proposal.

» The proposal intends to expand upon existing programs and operational procedures of the current Global Fund, which would be conducive to the successful implementation of the proposed reform.

» A lack of financial resources remains a key factor in determining the success or failure of the proposed expansion of the Global Fund and its ability to address the grand challenges of global health governance.


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nReferences1 Cometto G, Ooms G, Starrs A, Zeitz P. A global fund for the health MDGs? The Lancet [serial on the internet]. 2009

May [cited 2010 Nov 20]; 373 (9674):1500-1502. Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60835-7/fulltext.

2 Barmejo A, Epstein H, Sachs J. Towards a global fund for the health MDGs? The Lancet [serial on the internet]. 2009 Jun [cited 2010 Nov 20]; 373 (9681): 2111. Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61150-8/fulltext.

3 Key performance indicators [homepage from the Internet]. Geneva: The Global Fund; 2010 [updated 2010 Jan; cited 2010 Nov 20]. Available from: http://www.theglobalfund.org/en/performance/kpi/.

4 Funding a global health fund [homepage from the Internet]. London: The Guardian UK; 2010 [updated 2010 Mar 25; cited 2010 Nov 20]. Available from: http://www.guardian.co.uk/commentisfree/2010/mar/25/global-health-fund-funding-tb-aids.

5 Ooms G, Stuckler D, Basu S, McKee M. Financing the millennium development goals for health and beyond: sustaining the ‘big push’. Globalization and Health [serial on the internet]. 2010 [cited 2010 Nov 20]; 6 (17): [about 8 p.]. Available from: http://www.globalizationandhealth.com/content/6/1/17.

6 Kazatchkine, M. Increased resources for the global fund, but pledges fall short of expected demand. The Lancet [serial on the internet]. 2010 Oct [cited 2010 Dec 12]; 376: 1439-1440. Available from: http://www.theglobalfund.org/documents/ed/ED_LancetIncreasedResourcesForTheGlobalFund_Article_en.pdf.

7 The Lancet. The global fund: a bleak future ahead. The Lancet [serial on the internet]. 2010 Oct [cited 2010 Dec 12]; 376 (9749): 1274. Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61897-1/fulltext?version=printerFriendly.

8 The Lancet. The global fund: replenishment and redefinition in 2010. The Lancet [serial on the internet]. 2010 Mar [cited 2010 Dec 12]; 375 (9718): 865. Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60366-2/fulltext#.

9 The global fund for health? If donors pay up [homepage on the Internet]. New York: Open Society Foundations; 2010 [updated 2010 April 01; cited 2010 Nov 20]. Available from: http://blog.soros.org/2010/04/th-global-fund-for-health-if-donors-pay/print/.

10 Cohen J. The new world of global health. Science [serial on the internet]. 2006 Jan [cited 2010 Nov 20]; 311 (5758): 162-166. Available from: http://www.sciencemag.org/content/311/5758/162.summary/reply#sci_el_3137.

11 About the Global Fund: The global fund to fight AIDS, Tuberculosis and malaria [homepage on the internet]. Geneva: The Global Fund; 2010 [updated 2010; cited 2010 Dec 12]. Available from: http://www.theglobalfund.org/en/about/?lang=en.

12 The Global Fund to Fight AIDS, Tuberculosis & Malaria Bylaws, 2009, The Global Fund, as amended by 2009. Geneva: The Global Fund Board & Swiss Federal Supervisory Authority; 2009.

13 Atkinson AB. Funding the millennium development goals: A challenge for global public finance. Eur Rev. 2006;14 (4):555-564.

14 Resource Scenarios 2011-2013: Funding the global fight against HIV/AIDS, tuberculosis and malaria [homepage on the Internet]. Geneva: The Global Fund; 2010 [updated 2010 Oct; cited 2010 Nov 20]. Available from: http://ec.europa.eu/health/sexual_health/docs/ev_20100505_co05_en.pdf.

15. Fidler DP. International Institutions and Global Governance Program. The challenges of global health governance. Council on Foreign Relations Inc; 2010.

16 Time for a global fund for health? The IMF will have to get out of the way first… [homepage on the Internet]. Belgium: Eurodad; 2009 [updated 2009 Nov 04; cited 2010 Nov 20]. Available from: http://www.eurodad.org/whatsnew/articles.aspx?id=3899&print=yes.

17 Press Release: Donors commit US$11.7 billion to the global fund for the next three years [homepage from the Internet]. Geneva: The Global Fund; 2010 [updated 2010 Oct 05; cited 2010 Nov 20]. Available from: http://www.theglobalfund.org/en/pressreleases/?pr=pr_101005c.

A boy sitting in front of a shop in Bali, Indonesia. Jake Hirsch-Allen, 2010.

cHAPteR 6 BioSecuRity conceRt

By Tianxiu Hugh Guan


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nBackground

Since the events of September 11, 2001, the threat of terrorism has been high on the global agenda. The current shift in focus within the security field is a realization of the potentially devastating impact of threats such as biological warfare.1 Biosecurity, defined as the defence against both infectious disease and potential biological weapons, is gaining much attention in light of the lack of a global framework to control such risks. Current strategies for containing and deterring any biological outbreak are limited in effect as the issue is transnational, while present solutions are fragmented on an individual state basis. However, events like the SARS outbreak have shown that transmittable diseases spread quickly, disregarding man-made boundaries. Asymmetrical norms and regulations among nations allow outbreaks to slip through the cracks. Another problem linked with the status quo is the lack of representation of non-state actors. Any deliberation on a global biosecurity regime is mainly state-centric, as security is considered a matter of the state. However, the influence of non-governmental players is much greater in today’s globalized society. The marginalization of such important parties is detrimental considering the influence they wield. The ever-increasing number of state and non-state actors also means that the proliferation of biosecurity initiatives is disjointed. Various systems are put into place on a national and a global level, but there are no coordination mechanisms. The result is that the current state of biosecurity is fragmented, non-inclusive and lacking in direction. To address these challenges, Fidler and Gostin suggest a concert model of governance for the biosecurity realm.2

Abstract

the present concern with biological terrorism and emerging infectious diseases has caused a proliferation of biosecurity initiatives. However, the lack of cohesion on a global level is seen as a fatal flaw in ensuring biosecurity. Fidler and Gostin propose a concert model to coordinate the various actors. the biosecurity concert would use the united nations Security council to urge stakeholders to form initiatives based on the Biological Weapons convention and the international Health Regulations. in analyzing the proposal’s ability to solve global health challenges, the biosecurity concert is only a partial solution. Literature shows that a concert mechanism can provide leadership, but its ability to sustain funding and establish a coherent architecture for global health is questionable. issues such as the securitization of health is also concerning, which leaves the proposal in need of further debate to judge the full implications.

82 << Biosecurity Concert

biosecurity. The BWC is suggested as a hub as it is the major normative centre for the control of biological warfare. They do not suggest strengthening the convention, but understand that state and non-state actors can be influenced using the BWC to advance the global biosecurity regime. For the public health portion, the IHR is the proposed hub as it is the widely agreed upon centre of governance for epidemic disease. It is legally binding for all 193 member states of the World Health Organization, and can set a foundation for state and non-state actors to work together. Furthermore, the IHR is progressive in recognizing the influence of non-state actors and implementing procedures that have a dual public health and security aspect.2

To manage efforts within the biosecurity concert, the United Nations Security Council is asked to act as the coordinating body. The Security Council is identified as the leading actor in this proposal as it is mandated for managing all

The biosecurity concert proposal takes a networked governance approach to the classic concert mechanism. The closest modern day equivalent to the proposed model would be a combination of the G8 and the Counter-Terrorism Committee (CTC) of the United Nations Security Council. However, the biosecurity concert model would be more flexible in its methods by using both hard and soft power through multiple strands of governance, to achieve certain agendas. Instead of a singular entity or a singular international law, the concert approach tries to harness the energies and resources of all existing institutions, networks and frameworks to reach common mutual goals. These goals will be based around specific hubs of focus that will link agendas. Fidler and Gostin propose using the Biological Weapons Convention (BWC) and the 2005 International Health Regulations (IHR) as hubs. They believe these two existing laws can successfully integrate security and public health within

Surveillance measures for influenza.Vincent Huang, 2009.


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nconcert will hopefully coordinate efforts and create a stronger biosecurity regime.

Unlike some other proposals, the biosecurity concert mechanism for governance is one of compromise. On one hand, other proposals advocate maintaining the status quo which is deficient in overarching authority. On the other hand, some proposals call for authority to be relinquished to one institution to coordinate all biosecurity initiatives. The concert mechanism can be considered a middle way between these two options. The biosecurity concert would act as a coordinating body, but would not ask for health stakeholders to strictly follow the agenda of the Security Council. Any obligations and rights of the actors will be dependent on individual security partnerships that form based upon the BWC and IHR. The biosecurity concert still allows each actor to maintain independence. The main function of the proposal would be to link the agendas of various actors through the Security Council.2

Analysis

There are six grand challenges in global health governance identified by Gostin and Mok.3 To provide an evidence-based analysis on how well the biosecurity concert responds to the grand challenges, this section will use literature ranging from that produced by

global security issues. Under the Security Council, establishment of a Committee on Biological Security (CBS) is recommended to direct efforts that will be centred on urging nations to follow the BWC and the IHR. A secretariat is to be created to support the CBS. Using the BWC and IHR as hubs, the CBS will request the formation of biosecurity initiatives based around the goals of controlling biological weapons and infectious disease. These may be binding or non-binding, but should be accountable to the committee. On the country level, this proposal calls for national biosecurity interagency focal points that would coordinate biosecurity between ministries, consistent with the goals of the regional initiatives and the CBS. These focal points would additionally be responsible for overseeing and collecting data on national initiatives.2

To include non-state actors, the concert approach calls for allowing relevant parties to participate within the CBS and then also in regional initiatives and national focal points. Engaging non-state actors is important as they are an influential component for achieving biosecurity. Civil society biosecurity surveillance groups and non-state laboratories have broadened the current range of stakeholders that can play a role in ensuring biosecurity.2 Bringing these actors together through the biosecurity


Biosecurityconcert

• UN Security Council committee coordinating biosecurity initiatives

• Belief in Security Council • Existing initiatives

• Forum for dialogue • Best practices • New initiatives

• Formation of regional biosecurity networks

• Interlinked global biosecurity regime

• Nations will work together • Nations will follow suggestions

table 1: Key elements of Biosecurity concert Proposal


high level of compliance and progress in counter-terrorism initiatives from United Nations states.4,5 This shows that a Security Council committee can be effective in a leadership role. The success of the CTC signals viability for the CBS as a global health leader. The G8 has also shown that a concert mechanism is capable of achieving a leadership role. In global health, the G8 established the Global Fund to Fight AIDS, Malaria, and Tuberculosis (Global Fund), which was a large step forward in solving health challenges. One of the stated reasons for success of the G8 is its flexibility in dealing with the many new actors in global health.6 The emphasis on flexibility is also an important component of the biosecurity concert, thus predicting its possible success.2

the need to harness creativity, energy and resources

The evidence shows ambiguous findings for addressing this need. The CTC has been able to bring together international state-based actors.4 However, the CTC does not have any evidence of bringing together non-state actors. Organizations attending CTC meetings are all networks of states.7 The CTC has not included non-state actors such as civil society organizations, which raises the question of whether the

or about the G8 to articles on the United Nations Security Council. The CTC within the Security Council will be primarily examined, as it is the closest parallel to the CBS. The CTC will be used to predict how well the CBS can confront the grand challenges. There are several similarities between the CTC and the CBS that makes the comparison valuable. Both would be under the supervision of the Security Council, and both would use normative pressure in the pursuit of objectives linked to a certain hub – BWC and IHR for the concert and resolution 1373 for the CTC. Most importantly, both would try to foster coordination among various ongoing security initiatives at international, regional and sub-regional levels.2,4


The biosecurity concert can fill the current void in global health leadership. Like the CTC, the CBS would set an agenda by urging all parties to agree to certain objectives.2 The CTC and the CBS would both use normative practices such as urging nations to follow international law like the IHR to steer the direction of dialogue.2,4 The CTC is considered successful in influencing nations as displayed by the







Biosecurityconcert

• Achievable through the Security Council

• Unclear if parties other than states can be harnessed

• Achievable through common dialogue space

• Health systems are strengthened; basic survival needs are forgotten

• Uncertain as it is dependent on individual initiatives

• Doubtful unless monitoring and enforcement measures are established

table 2: How the Biosecurity concert Addresses the Six Grand challenges in Global Health Governance


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urge nations to solve biosecurity related issues.2 This idea that a guiding committee can engage actors to work together is supported in the current proceedings of the CTC and of the G8. The CTC has urged successfully for international, regional and sub-regional stakeholders to work with each other to develop resources. Using its leadership capabilities, the CTC has brought together more than 50 different international organizations, ranging from financial institutions to regional security organizations.7 Many of these organizations have agreed to share codes of practice and help capacity building in security in developing nations.10,11 Likewise, the G8 members have had success bringing together many stakeholders to finance the Global Fund.8 States as well as non-government organizations have come together to use the Global Fund as a coordinating centre for funding initiatives.8 The G8 illustrates that a concert mechanism composed of a select few

Security Council would be willing to include non-state players on the CBS. For the G8, there is further conflicting evidence. An organizational strength of the G8 is its ability to engage non-state stakeholders such as private enterprises and non-government organizations. A result of this ability to harness non-state players was the establishment of the Global Fund.6 Although the Global Fund was a breakthrough in consolidating funding for initiatives, it is constantly underfinanced.8,9 This presents the issue of the questionable ability of a concert to gather adequate and sustainable funding for global health.

the lack of collaboration and cooperation between players

Although the CBS will not include all of the key stakeholders on the committee, the mandate of the CBS will be to bring different parties together. The hubs of the BWC and IHR will be used by the CBS as a form of normative pressure to

Public health vaccination campaign.Piyal Adhikary, 2010


disadvantaged nations in developing best practices for counter-terrorism.10 However, since the biosecurity concert is mainly concerned with infectious diseases, it does not adequately focus on basic survival needs. Policies will look at surveillance, prevention and response, but not at the underlying factors that engender the environment for such infectious outbreaks. Examining an existing biosecurity initiative like the Global Security Health Initiative has displayed limited concern on basic survival needs with a lack of language urging its importance. The ministerial statements from the Global Security Health Initiative only stress defensive measures against infectious

can advocate for change that is then accepted by the global community.

the neglect of basic survival needs and health systems strengthening

The biosecurity concert would only partially address this goal. Health systems may be strengthened as the biosecurity concert will recommend better health surveillance measures and human resource development, as both are connected to greater health security.2 Literature on the CTC has shown that there is a precedent for informal networks to build capacity on the system level.4,10 Organizations are coming together to share resources with

United Nations Security Council.Pete Souza, 2009.


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nthe need for accountability, transparency, monitoring and enforcement

This is another problematic challenge for the biosecurity concert. The CBS would ask for reports on the progress of any initiatives undertaken. This ensures accountability is in place for global biosecurity partnerships. Although reports are to be sent to the CBS, enforcement depends on the partnerships that are established, as the CBS will not act as a regulatory or sanctions committee.2 Therefore, the CBS would not be able to intervene in any initiatives that fail to send in reports or those that fail at their duties. These issues are paralleled by the CTC. Although nations have submitted reports to the CTC and have ratified counter-terrorism conventions, nations either do not implement the conventions or implement them poorly.14 The CTC does not have the power to enforce such conventions through prosecution or condemnation.4 The CTC recognizes non-compliance as an issue of the lack of monitoring within countries.14 As a result of this problem, the Security Council established a Counter-Terrorism Committee Executive Directorate (CTED) to monitor implementation.15 Unless the biosecurity concert also creates monitoring commissions or enforcement strategies, then the limited effectiveness of accountability measures alone may not fully resolve this challenge.

diseases, and does not mention anything about basic needs.12

the issue of funding and priority-setting

The biosecurity concert does not solve this issue fully. Actors will agree upon where the funding goes and how much is given. There is no mechanism in place within the BWC or IHR dealing with the recommended amount or distribution of funding. The CBS can strongly advocate a specific plan, but the actors would still control the source and the distribution of funds. Again for priority-setting, the committee can support a specific issue over another, but the real power would lie in the agreements formed between stakeholders. The CTC highlights both problems. It provides a forum for stakeholders to come together, but does not deal with the financial commitments or allocation, nor with setting priorities within implementation of resolution 1373.4 The issue of funding is also especially evident in the G8 concert example. Countries can make commitments to solve certain problems, but commitments are not always followed through in terms of financial resources, and may also not be equitable. Although G8 nations have pledged to raise their development aid efforts to 0.7% of their GDP, none of the nations have been close to meeting this target.13


Biosecurityconcert

• United Nations Security Council • Nation-states

• Coordinate biosecurity initiatives through IHR and BWC

• Moderate: need of secretariat for committee

• Lack of belief in Security Council

• Non Security Council nations

• Marginalize non-state actors • Narrow focus on health

table 3: implementation considerations for the Biosecurity concert Proposal


follow.4 However, the proposal may face opposition from marginalized nation-states, as power is being consolidated in the Security Council which many view as non-equitable.16

Feasibility and Practicality for implementation

Evidence also shows that the global biosecurity concert proposal is feasible in terms of cost. Operationally, the proposal works within existing institutions with existing mechanisms, reducing waste by limiting the amount of additional bureaucracy.2 Considering the speed of CTC establishment and its longevity, there should not be large obstacles to creating a committee that follows its example.4 Politically, countries are concerned with security, which provides an incentive for states to establish a coordinating body for biosecurity efforts. Over the past decade, many resolutions related to security have


A barrier for implementation of many ideas is a lack of political attractiveness. For the biosecurity concert, the proposal is politically attractive. Judging from the current atmosphere of global health, there is a need for a coordinating body. A policy window exists for consideration of governance schemes. Biosecurity has already been partially legislated under resolution 1540 of the Security Council, setting a precedent for the proposed concert mechanism.2 The current proposal also allows actors to keep their present level of power and independence while introducing a mechanism for coordination of their initiatives. The unique framework means that stakeholders can still choose their own agendas without formal top-down control. The view of the CTC as non-confrontational in regards to governing as an overarching authority has gathered widespread support, setting a possible example for the CBS to

Influenza pandemic in Mexico.Eneas/Eneas de Troya, 2009


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nAnother issue is that the biosecurity concert would be based within the Security Council, which is the United Nation’s core security organ. Many parties do not agree with the current limited membership of the Security Council for a variety of reasons.16 Reform of the Security Council has even been recommended by the United Nations itself.22 A long-standing problem with the Security Council is the lack of equality for many countries, as there are only five permanent members, each with the special ability to veto any proposals.16,22 Especially given the global nature of health, putting power in the hands of a select few does not engender trust globally. The Security Council may not be the best international institution to oversee biosecurity efforts due to the existing concerns with its decision-making model.

A third implication is the narrow focus on global health if this governance mechanism is established. In the context of global health governance reform, the biosecurity concert may not meet all the needs of the global health field. The biosecurity concert, as the name suggests, is mainly concerned with the security aspects of health. Global health is more than just security and the control of infectious disease. It is multi-factorial with issues of development and humanitarianism. Focusing on security ignores all these other issues, which frames health as one dimensional.23 This would overlook the many varied actors in global health and would continue the fragmentary nature of global health governance and delivery.

conclusion

From the present state of affairs, it is still unclear if the biosecurity concert proposal should be implemented. If it is to be the

been passed by the Security Council, such as resolution 1373 and resolution 1570. Concerts such as the G8 have also established regional biosecurity initiatives like the Global Security Health Initiative.2 Economically, the proposal is also moderate in cost as it only asks for funding for a secretariat to support the CBS. Currently for all Security Council affairs, there is a proposed budget of US$14.5 million, which is 1.5% of the total UN political affairs budget.17 However, the financial cost of the committee may face resistance if the role of the CBS is expanded to monitoring implementation of initiatives. For the proposed budget in 2010, the CTED asked for close to US$9 million in funding.18

Further considerations

The global biosecurity concert has several implications for global health governance. The most concerning is the securitization of health. Securitizing health still frames, though more subtly, the provision of health as a matter of the state. This only superficially involves non-state and international actors, despite the current understanding of global health as a multi-factorial system. The majority of power is still with national governments, while non-state actors are only supporting players.19,20 Additionally, securitization introduces radically different actors into the health sphere, such as the military establishment, raising a further cause for concern. The neutrality and independence of health is compromised with the inclusion of the military, as they are viewed quite differently than that of the usually humanitarian perspective of health.21 This may cause nations to be more suspicious of each other when negotiating health partnerships.21


global health governance reform of choice, issues about extensive securitization of global health and using the Security Council need to be reconciled with current global challenges and criticisms. Evidence is still unclear about the effectiveness of contemporary concert mechanisms, and on the Security Council in coordinating security. Literature has shown that a Security Council-based concert mechanism can fill the role of global health leader, but issues about funding and creating a sustainable architecture for global health is in need of more research.

Key Messages

» Establish a working group to evaluate whether a biosecurity concert could offer a sustainable approach to funding and governance in global health.

» Generate dialogue to discuss implications of the securitization of global health.

» Change the existing biosecurity paradigm to encompass all perspectives of health, including humanitarianism and international development.


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nReferences1 Fidler DP. Public Health and National Security in the Global Age: Infectious Diseases, Bioterrorism, and Realpolitik.

The George Washington International Law Review. 2003;35:787.2 Fidler DP, Gostin LO. Biosecurity in the global age: biological weapons, public health, and the rule of law. Stanford:

Stanford University Press; 2008.3 Gostin LO, Mok EA. Grand challenges in global health governance. Br.Med.Bull. 2009;90(1):7-18.4 Rosand E. Security council resolution 1373, the counter-terrorism committee, and the fight against terrorism. The

American Journal of International Law. 2003;97(2):333-41.5 Biersteker TJ. Counter-Terrorism Measures Undertaken under UN Security Council Auspices. In: Bailes AJK,

Frommelt I editors. Business and Security: Public–Private Relationships in a New Security Environment. Oxford: Oxford University Press; 2004. p. 59–75.

6 Kirton JJ, Mannell J. Current. The G8 and global health governance. In: Cooper AF, Kirton JJ, Schrecker T, editors. Governing global health: challenge, response, innovation. Hampshire, England: Ashgate Publishing; 2007. p. 115-46.

7 U.N. Security Council. List of participants in CTC special meeting, 6 March 2003, with relevant contact details, 21 March 2003, (S/AC.40/2003/SM.1/3/Rev.1). Official Report. (Online Report)

8 Radelet S. The Global Fund to Fight AIDS, Tuberculosis and Malaria: Progress, potential, and challenges for the future. Washington, DC: Center for Global Development; 2004.

9 The Global Fund to Fight AIDS, Tuberculosis and Malaria, 19th Board Meeting. Report of the finance and audit committee, 6 May 2009, (GF/B19/6). Official Record. (2009 Online Report)

10 Ward CA. Building capacity to combat international terrorism: the role of the United Nations Security Council. Journal of Conflict and Security Law. 2003;8(2):289-305.

11 U.N. Security Council Counter-Terrorism Committee. Survey of the implementation of Security Council Resolution 1373 (2001) by member states, 3 December 2009, (S/2009/620). Official Report. (2009 Online Report)

12 Global Health Security Initiative [Internet]. Canada: Global Health Security Initiative; c2001-2010 [cited 2010 Nov 10]. Ministerial statements London, United King – 4 December 2009: tenth ministerial meeting of the Global Health Security Initiative (GHSI); [about 3 screens]. Available from: http://www.ghsi.ca/english/statementlondon2009.asp

13 Labonte R, Schrecker T. Committed to health for all? How the G7/G8 rate. Social Science Medicine. 2004;59(8):1661-76.

14 U.N. Security Council. Report by the Chair of the Counter-Terrorism Committee on the problems encountered in the implementation of Security Council resolution 1373 (2001), 26 January 2004, (S/2004/70). Official Report. (Online Report)

15 U.N. Security Council. Organizational plan for the Counter-Terrorism Committee Executive Directorate, 12 August 2004, (S/2004/642). Official Report. (Online Report)

16 Fitzgerald A. Security Council reform: Creating a more representative body of the entire UN membership. Pace International Law Review. 2000;12(2):319-65.

17 U.N. General Assembly, 64th Session. Proposed programme budget for the biennium 2010-2011: Part 2 political affairs: Section 3 political affairs, 15 April 2009, (A/64/6 (Sect.3)). Official Record. (2009 Online Report).

18 U.N. General Assembly, 64th Session. Budget committee takes up proposed $600 million in financing for 27 special political missions in 2010, 17 December 2009, (GA/AB/3937). Press Release.

19 Kelle A. Securitization of international public health: implications for global health governance and the biological weapons prohibition regime. Global Governance. 2007;13(2):217-35.

20 Davies SE. Securitizing infectious disease. International Affairs. 2008;84(2):295-313.21 Aldis W. Health security as a public health concept: a critical analysis. Health Policy Plan. 2008;23:368-75.22 U.N. General Assembly, 59th Session. Report of the Secretary-General’s high-level panel on threats, challenges and

change, 2 December 2004, (A/59/565). Official Report. (Online Report)23 World Health Organization. The future of financing for WHO. Report of an informal consultation convened by

the Director-General. Geneva: World Health Organization; 2010.

Slum in Amritsar (northern India) that would benefit from development assistance.Rubeeta Gill, 2009.

cHAPteR 7 GLoBAL deVeLoPMent oRGAnizAtion

By Rubeeta Gill


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nintroduction

With the proliferation of formal and informal global health actors over the last decade, the numbers of ideas, initiatives and institutions have also increased.1 An estimate shows that there are more than 40 bilateral donors, 26 UN agencies, 20 global and regional funds, and 90 global health initiatives currently active.2 This sudden abundance of global health actors has not been organized effectively, giving rise to seeming chaos.3 In addition, some major organizations are failing to achieve their development goals.

The WHO has been repeatedly criticized for not assuming its intended role of leadership effectively.3,4,5,6 Further, while it has made research a priority7,8 and while it strives to conduct sector-specific collaborations with other organizations working towards similar goals,9 it has failed to allocate its funds appropriately, heavily skewing its budget towards issues of greatest concern to its donors, as opposed to issues prioritized by people in recipient states.6,10

The World Bank has also been criticized for falling short of expectations. While it is active in amassing knowledge and helping countries build research capacity,11,12 it does not place enough emphasis on achieving the goals of all its programs.13 One-third of its 220 projects under scrutiny failed to achieve their goals in an evaluation.11 These goals were also misconceived in that only a small percentage of them were relevant to the World Bank’s remit of poverty reduction.13 Of this small percentage, little had been done to measure how successful these initiatives had actually been in reducing poverty.13

The IMF collaborates with the World Bank, the WTO, UN agencies and regional development banks,14,15 and is accountable

Abstract

the world’s major global health organizations such as the World Health organization (WHo), the World Bank, the international Monetary Fund (iMF), and the World trade organization (Wto) have been repeatedly criticized for not being effective in their development work. their failures have left global health’s most pressing challenges unresolved, among them the six grand challenges of global health governance identified by Gostin and Mok. A proposal for a Global development organization (Gdo) has been offered as an answer to effective development work within the realm of global health. this paper will analyze this proposal in accordance with whether and how they address the six grand challenges.

94 << Global Development Organization

by Richard Horton,4 would aim to fulfil the unmet needs visible in the development shortcomings of the organizations mentioned above.

A GDO would collaborate with other organizations, governments and non-state actors to become a multi-level and multi-purpose structure to oversee global development work. It would serve to advocate for global action on human development, to be the lead scientific and technical agency for development, to coordinate bilateral and multilateral development programs, and to set standards for development work. It would also function to make globalization work for sustainable human development, achieve the Millennium Development Goals (MDGs),

to its 187 member governments.16 However, it has been criticized for denying countries opportunities to make their own choices for social and economic development,14 for being biased in favour of its rich and influential donors,3 and for failing to conduct impact assessments of its policies.14 Finally, the WTO has been accused of frequently excluding developing country members from its negotiations, making decision-making a partial and non-participatory process.4

Amidst criticisms of the aforementioned global health organizations, a call for new governance architecture for global health has emerged.17 Among a plethora of proposed reforms, one proposal calls for the creation of a Global Development Organization (GDO). This proposal, offered at one point

Global health leader speaks about the lack

of transparency within major

organizations involved in

development work at the

Unite for Sight Global Health Conference at

Yale University, Connecticut.

Rubeeta Gill, 2010.


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nassuming that role effectively.17 It has also been said to have done little to address this shortcoming, which has led to its increased marginalization, especially over the last two decades.5 It is within this atmosphere that a GDO was proposed. One of the first arguments made by Horton in support of this idea is that there is no institution to lead and systematically govern development efforts amidst rampant globalization.4 The proposed GDO would aim to assume leadership by setting standards for best practice and overseeing the global development process.4 The failures of the WHO and other organizations in meeting their set standards in development work seem to strengthen the need for an effective development organization. In addition, a recent report published by the WHO has highlighted that the WHO may cease its work on development altogether, further strengthening this need.18

While a GDO might address the lack of global health leadership in development work, it cannot be contested that the WHO still holds favour in the eyes of many. Despite its failures, the WHO is still believed by some to be the best organization to lead, by virtue of its role in setting evidence-based norms on technical and policy matters, highlighting best

systematically collect evidence about the theories and practices of development work, and collaborate with governments to build institutions and systems to address economic, environmental and epidemiological threats. Finally, it would strive to create partnerships to help finance development, disseminate information about best practice to partner agencies, initiate long-term research programs on development issues, and strengthen information capacity and communication technologies in developing countries.4

This paper will now examine whether and how the GDO would address the Six Grand Challenges of Global Health identified by Gostin and Mok.3

Grand challenge 1: the lack of global health leadership

A lack of leadership has been recognized within global health.3 This was not supposed to happen: when the UN established the WHO, it was intended to take on the leadership role to direct all efforts and initiatives within the development sphere.3,6,17 However, while many acknowledge the WHO’s leadership potential, most have criticized it as not


Globaldevelopmentorganization

• Organization to advocate for global action on human development

• Research planning • Funding donors • Government partnerships • Time • Money

• Knowledge access and delivery • Collaboration & coordination • Increased accountability

• Collect evidence about theories and practices of develop-ment work • Create partnerships for development

• Collaborated & coordinated players within human development • Knowledge and research program for development efforts • Achievement of the MDGs

• Granted the political power and legitimacy, social acceptance, and funding to operate

table 1: Key elements of the Global development organization Proposal


manpower and resources for global health programs and other initiatives.3 The failure of multiple players to harness them in an organized way has created the need for a governance system that will create incentives and facilitate, coordinate and channel the activities of actors.3 The ultimate goal would be to generate and align the incentives to promote solutions for global health improvement.3 The formation of a GDO holds promise to fulfil this unmet need by becoming a knowledge organization.4

In his proposal, Horton argues that development refers to the construction of adaptability, which comprises information – both the ability to create it and to have access to it.4 As it stands now, he believes that development has come to be perceived purely as an economic process, something a GDO would seek to change.4 It would aim to become the go-to centre for knowledge and resource acquisition. It would attempt to improve the quality and magnitude of useful information available to partner agencies, distribute information about best practices to partner agencies, and strengthen information technologies, communication technologies and information capacity in developing countries.4 A GDO would also systematically collect evidence about the impact of development (theory and practice)

practices that improve health worldwide, and coordinating action to address global health threats.3,17 Given the legitimacy the WHO possesses, some are suggesting its reinvention to improve its leadership, as opposed to dismissing it altogether due to its failures.19 They believe that investing resources and efforts into revamping the WHO and other existing structures would be a better course of action than to create new bodies (such as a GDO), which could draw funds further away from the WHO’s development initiatives.1,19 It is therefore safe to assume that even if a GDO were to be instated amidst such an atmosphere, it would be scrutinized. Moreover, if a GDO goes on to be successful in its leadership endeavours, other development organizations may be threatened by that progress and consequently become resistant to sharing funds, resources and knowledge with a GDO.

Grand challenge 2: the need to harness the creativity, energy and resources for global health

The proliferation of institutions, actors and initiatives within the global health realm has also created a plethora of creative ideas,







Globaldevelopmentorganization

• Might be met by criticism and scrutiny by those in favour of the WHO’s leadership

• Large and successful role in generating research, knowledge, and creativity

• Part of expected functions but seems unlikely to be successful

• Could be successful while contributing towards MDG achievement

• Might not be effective, as “creating partnerships to finance development” lacks ability to be binding

• Will make other organizations more accountable for their actions

table 2: How the Global development organization Addresses Six Grand challenges in Global Health Governance


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nto create the power of information and evidence to guide governing actions.17

Grand challenge 3: the lack of collaboration and coordination between multiple players

It has been mentioned that there is a lack of coordination and collaboration among the multiple players in global health. This issue worsens as the numbers of actors, institutions and initiatives increase, resulting in the duplication of funding, programs and activities within global health.3,17 Furthermore, it adds to the competition between NGOs and local service providers for funds and resources.3 A system of

on populations where development work efforts are ongoing,4 enabling consistent assessment and evaluation of progress. This pooling of knowledge, creativity, energy and resources from various state and non-state actors would create an organized platform from which resources can be gained, measured and allocated in a systematic fashion to the development work most needy at any given time, with consistent progress evaluations. Also included would be the initiation of a long-term research program into development issues.4 If a GDO does indeed act upon these objectives, and provided it includes health in its list of responsibilities, it would have the potential

Two abandoned deaf children at the Bhagat Puran Singh School for the Deaf at the Pingalwara Organization in Manawala (northern India), an NGO that receives no

assistance from international or national organizations involved in development work.Rubeeta Gill, 2009.


address economic, environmental and epidemiological threats.

While success in these areas could potentially make great strides in improving coordination and collaboration between multiple players, the difficulty in translating the theory into actual practice must be taken into account. The United Nations Development Programme (UNDP) can be considered for comparison. With a similar goal of coordination, the UNDP serves as the coordinator of development activities for the United Nations system as a whole.20 Also, the UN Secretary-General has asked the UNDP to act as the coordinator of the Millennium Development Goals within the UN system.20 Despite having an integral role in coordinating and collaborating, the UNDP has fallen short of accomplishing its expected objectives. Horton argues that

governance that promotes effective partnerships and coordinates initiatives is needed.3 This is a gap that the proposed GDO is expected to fill. Some of its main functions, if established, will be to:4

» Coordinate bilateral and multilateral development programs;

» Strengthen and coordinate the expertise, resources and networks that are presently distributed across many different multilateral institutions;

» Help to avoid duplication of work across existing agencies;

» Coordinate the activities of all national departments for international development; and

» Collaborate with governments to build institutions and systems to

Group protesting the lack of action taken

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organizations at the International AIDS

Conference in Vienna, Austria.

Rubeeta Gill, 2010


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nand a lack of direction for development initiatives.3,21 A GDO might be able to address these two needs. Basic survival needs have been defined to include sanitation, pest control, clean air, safe drinking water, tobacco control, nutrition, essential medicines, vaccines and functioning health systems.3 Some of these needs, including the strengthening of health systems, could potentially be served through efforts towards achieving the MDGs, which would be included in a GDO’s list of functions. However, there is no clear indication that fulfiling such needs would be a priority for a GDO, given its central focus on knowledge and resources.

Grand challenge 5: the issue of funding and priority setting

Global health is experiencing a lack of prioritization in terms of the increased funding it is receiving. In most organizations involved in development work, initiatives being funded are determined by the agendas of a small number of wealthy donors, causing a diversion of funds from the most-needed initiatives.3,22 For example, 75% of the WHO’s funding is directed to infectious diseases in the West Pacific region, where 75% of the healthcare burden stems from non-communicable disease.21 This is unfortunate, as resource allocation based on the attainment of basic survival needs, support for basic infrastructure and capacity building, and cost-effective interventions (as opposed to resource allocation based on wealthy donor agendas) have the potential to make more effective use of donor funds.1

It is difficult to predict whether or not a GDO would be successful in effectively prioritizing the allocation of its funds. To begin with, no indication is made in the

the UNDP lacks the power and political authority to engage in fresh thinking, policy development and advocacy.2 Therefore, the ability of a GDO to foster coordination and collaboration between multiple players will depend on the powers and legitimacy it is granted. Even if these elements are eventually granted to a GDO, it is uncertain as to how its efforts to foster collaboration will be any different from what the UNDP already does and has done in the past. Currently, there is no such well-researched, evidence-based plan for a GDO to accomplish organized coordination. Before there is a systematic approach to address this goal, instating a GDO might be of little benefit. Again, it is important to remember that existing bodies of the UN (such as the UNDP), considered to possess the highest level of powers and political capability, have not been fully successful. Despite these challenges, the conversion of the UNDP to a GDO can be considered. The UNDP’s work already falls within the goals of a GDO, and such a conversion would enable a GDO to work towards gaining more power and legitimacy than what the UNDP now possesses. Using the UNDP’s existing approaches as an initial platform, a GDO might be able to reform unsuccessful approaches of the UNDP to create newer approaches for coordination. On its own however, it may be difficult for a GDO to overcome this grand challenge.

Grand challenge 4: the neglect of basic survival needs and health systems strengthening

Currently, basic survival needs and the building of health systems are two areas within global health governance that tend to be neglected, contributing to fragmentation


Grand challenge 6: the need for accountability, transparency, monitoring and enforcement

As previously mentioned, an issue development agencies currently face is the lack of a way to hold rich states and partners accountable for their pledges to provide assistance to countries that need it.3 While organizations such as the WHO are officially accountable to their member states, they often lack realistic targets for actions they take to promote health and fulfil their promises.3 Overall, there is a need for accountability, transparency, monitoring and enforcement.17 As further evidenced in the report of the UN Secretary-General about progress on Agenda 21 (a development-based action plan of the UN),23 there is undeniably a gap in implementation4 despite increased efforts to monitor and evaluate the progress of health initiatives. This reduces the commitment of actors to one of a voluntary nature, which in turn contributes to the lack of implementation and the increased difficulty in holding these actors accountable. A GDO would

proposal as to how a GDO would even obtain its funds, let alone have an organized plan of prioritizing the allocation of these funds. The proposal makes clear that a GDO would help fund development efforts by creating partnerships.4 However, it is likely that no extensive thought has yet been given to determining the specific causes within the development sphere that a GDO would fund, or towards establishing which causes would take priority over others. Even if this is done eventually, the next steps of action are unclear. A GDO would need to realize a means through which donations can continue being channeled, while programs high on the recipient country agendas are funded. It would also need to create a way for this system to prevail. Unless this occurs, a GDO would likely not be an effective allocator of funds.

Too many global health actors on the

same ground, contributing to

seeming chaos.Rubeeta Gill, 2009.


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nIt seems unlikely that an organization addressing only one of the six major gaps in global health governance would be given the permission, mandate, political power and legitimacy to operate. This is especially so amidst a political, social and economic atmosphere that resonates more with investments being made into improving existing global health infrastructure, than with the creation of new infrastructure. The next suggested steps to be taken in forming strong global health governance seem clear: if any new initiative is to be realized, it must be inter- and trans-sectoral in nature, adopt a multi-sectoral and multidisciplinary approach, be inclusive, welcoming of diversity, and sensitive to local needs, capacities and knowledge.17 As well, it would need to clearly define the roles and responsibilities of actors, have a transparent system of monitoring and evaluation, and channel information and evidence.17 Only all-inclusive suggestions are likely to be granted political powers, acceptance and funding. The GDO proposal currently does not include all of the aforementioned elements, which reduces its political, social and economic feasibility, and likelihood to be established.

The question of cost must also be addressed. The creation of a GDO would first incur a resource cost. There will need to be money and other resources to fund

aim to “improve the quality and range of information available to partner agencies and hold those institutions accountable for the impact of their work on development”.4 By adding accountability to other organizations, a GDO would indeed contribute to an increase in transparency and consequently in the implementation of pledged causes. Again, however, the feasibility of actually having the structure to make other organizations accountable must be considered. The GDO would also have to create a means for itself to be accountable in its practices.

Feasibility

This analysis has elucidated that if a GDO were indeed implemented, it would be able to fill gaps primarily within the second grand challenge: the harnessing of creativity, energy and resources for global health. While it may also work minimally in improving basic survival, priority setting and making other organizations accountable for their commitments, the benefit of a GDO would be centered on resource and knowledge acquisition, access and allocation. The next step is to consider how practical it would be to implement an organization that will primarily address only one of the six grand challenges.



• GDO members • Governments • Other development agency members

• Research and knowledge acquisition • Adding accountability to organizations

• Abandon-ment of other development organizations • Diverted funds and resources

• Lack of power • Lack of legitimacy • Lack of funding

• From other development agencies with overlapping functions, as a GDO could potentially divert funds away

• Addition to sea of overlapping organizations

table 3: implementation considerations for the Global development organization Proposal


How many members will be required? How and on what basis will these players be chosen? Once chosen, what will their responsibilities, obligations and rights be? How will a GDO obtain the mandate, legitimacy and means to make progress in human development? How will a GDO ensure that it does not overlap with other organizations in a counterproductive manner? What system will be used to measure the success of a GDO? How will a GDO display its progress to members of the international community? If a GDO is to be created, these difficult questions must be considered.

conclusion

This paper has analyzed the foreseeable strengths and weaknesses of the proposal to create a Global Development Organization. The analysis indicates that the creation of a GDO at this time seems politically, socially and economically unfeasible. Unless changes are made, a GDO is unlikely to be considered sufficiently equipped to bridge the gaps in global health governance and development work.

and sustain the organization, its programs and physical infrastructure. More than likely, these resources will be diverted from other development agencies performing similar work with poor results. There will also be a time cost: it will be a long period of time before a GDO will be established and functioning strongly. During this time period, existing organizations will be less likely to improve their limitations in anticipation of a GDO that would possibly fill in gaps. Lastly, there is an opportunity cost involved in adopting this proposal: if a GDO is created, other commendable development organizations might be abandoned. As well, it will become less likely for new development organizations to be suggested and created. The reluctance to invest in other development organizations, coupled with the costs associated with establishing a GDO, reduces the feasibility of creating a GDO at present.

Further considerations

There are many questions left unanswered. If a GDO were to be created, who will be involved in its creation and maintenance?

Key Messages

» More effort should be put into calculating the financial, time and opportunity costs of implementing a Global Development Organization (GDO).

» A cost-benefit analysis should be undertaken to determine whether the services offered by a GDO would be sufficient to justify the costs of its creation and maintenance.

» Existing organizations would benefit from an evidence-informed list of strategies to expand and improve their development efforts.

» Additional research would be helpful to predict how the global community will receive a GDO, especially amidst the current political, social and economic atmosphere that favours the reinvention of existing structures instead of creating new ones.


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nReferences1 Filder DP. The Challenges of Global Health Governance. CFR International Instituitions and Global Governance.

2010 May:1-31.2 McColl K. Europe told to deliver more aid for health. Lancet. 2008 21 Jun;371(9630):2072-3. 3 Gostin LO, Mok EA. Grand Challenges in Global Health Governance. Brit Med Bull. 2009;90:7-18.4 Horton R. The Case for a Global Development Organisation. Lancet. 2002 Aug 24;360:582-3.5 Horton R. WHO: The Casualties and Compromises of Renewal. Lancet. 2002 May 4;359(9317):1605-11.6 Sridhar D. Global Health – Who Can Lead? Chatham House Publishing. 2009 Feb:[2 p.]. Available from: http://

www.globaleconomicgovernance.org/wp-content/uploads/Global-Health-Who-Can-Lead.pdf 7 World Health Organization [Internet]. [updated 2010; cited 2010 Oct 26]. Available from: http://www.who.int/

en/ 8 The WHO Agenda. World Health Organization [Internet]. [updated 2010; cited 2010 Oct 26]. Available from:

http://www.who.int/about/agenda/en/index.html 9 Partnerships and Collaboration. World Health Organization [Internet]. [updated 2010; cited 2010 Oct 28].

Available from: http://www.who.int/surgery/collaborations/en/10 Stuckler D, King L, Robinson H, McKee M. WHO’s budgetary allocations and burden of disease: a comparative

analysis. Lancet. 2008 Nov 1;372(9649):1563-9.11 The World Bank [Internet]. [updated 2010; cited 2010 Oct 26]. Available from: http://www.worldbank.org/

reference/12 Ruger JP. Global health governance and the World Bank. Lancet. 2007 Oct 27;370(9597):1471-4.13 The World Bank. Improving Effectiveness and Outcomes for the Poor in Health, Nutrition and Population: An

Evaluation of World Bank Group Support Since 1997. 2009:1-187.14 International Monetary Fund [Internet]. [updated 2010; cited 2010 Nov 2]. Available from: http://www.imf.org/

external/about/collab.htm 15 Khor M. A critique of the IMG’s role & policy conditionality. Third World Network [Internet]. 2001 [cited 2010

Oct 24]: [25 p.]. Available from: http://www.twnside.org.sg/title/geseries4.htm 16 Accountability. International Monetary Fund [Internet]. [updated 2010; cited 2010 Nov 2]. Available from:

http://www.imf.org/external/about/govaccount.htm17 Sridhar D, Khagram S, Pang T. Are Existing Governance Structures Equipped to Deal with Today’s Global Health

Challenges - Towards Systematic Coherence in Scaling Up. Glob Health Gov. 2008 Sept;2(2):1-25. 18 Chan M. The future of financing for WHO. Introductory remarks at an informal consultation; 2010 Jan 12. 19 Fee E, Cueto M, Brown TM. WHO at 60: Snapshots From Its First Six Decades. Am J Public Health. 2008

Apr;98(4): 630-3.20 United Nations Development Programme. UNDP for Beginners. 2006 Jun;2:1-25. 21 The World Health Report. World Health Organization [Internet]. [updated 2010; cited 2010 Oct 27]. Available

from: http://www.who.int/whr/previous/en/22 Stuckler D, King L, Robinson H, McKee M. WHO’s budgetary allocations and burden of disease: a comparative

analysis. Lancet. 2008 Nov 1;372(9649):1563-69. 23 Agenda 21. UN Department of Economic and Social Affairs [Internet]. [updated 2010; cited 2010 Dec 10].

Available from: http://www.un.org/esa/dsd/agenda21/ 24 IMF Publications. International Monetary Fund [Internet]. [updated 2010; cited 2010 Nov 4]. Available from:

http://www.imf.org/external/pubind.htm25) Sachs J. The IMF Is a Power Unto Itself. The Financial Times. 1997 Dec 11. Available from: http://www.

uv.es/~fores/AcosoTextual/sachsbio.html 26 WTO and Global Health [Internet]. Available from: http://www.ipfw.edu/hri/WTO/WTOpaper-anna.pdf 27 Fergusson IF. CRS Report for Congress: The WTO, Intellectual Property Rights, and the Access to Medicines

Controversy. [updated 2006 Dec 12; cited 2010 Nov 26]. Available from: http://www.fas.org/sgp/crs/misc/RL33750.pdf

28 Oxfam International. Oxfam Briefing Paper: Empty Promises. 2009 Jul 16; 131(2):1-38.29 The World Bank and global health: Promising to try harder. The Economist. 2009 Apr 30 [cited 2010 Oct

16]:[about 1 p.]. Available from: http://www.economist.com/node/13579721 30 Evaluating The World Bank’s Approach to Global Programs. The World Bank [Internet]. [updated 2010; cited 2010

Oct 14]. Available from: http://www.worldbank.org/oed/gppp/index.html31 The World Health Organization. The World Health Report 2000: Health Systems: Improving Performance. 2000:1-

206. 32 ACTA is secret. How transparent are other global norm setting exercises? 2009 Jul 21. Available from: http://www.

keionline.org/miscdocs/4/attachment1_transparency_ustr.pdf 33 Partnerships at Work. The World Bank [Internet]. [updated 2010; cited 2010 Oct 10]. Available from: http://

go.worldbank.org/G7VSZBNMF0 34 Ballou-Aares D, Obst V. Transform or Be Transformed: Leading a Global Health Organization during Uncertain

Times. Dalberg Global Development Advisors.

Meeting of the World Health Organization’s Executive Board in Geneva, Switzerland.Steven J. Hoffman, 2007.

cHAPteR 8 netWoRKed GoVeRnAnce

By Samantha Buttemer and Harkiran Kalkat


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nintroduction

The concept of networked governance in global health was born from the idea of creating horizontal networks of organized interest as a means of producing public policy and governance. This general research began with Marin and Mayntz (1991) and Kooiman (1993).1 These researchers promoted the analysis of networks in order to understand the functionality of networks between a variety of actors. Mayntz (1993) described governance networks as a method to create policy when governing processes are not fully controlled by government, and involve a variety of public and private actors.1 The interactions of the actors form a fairly stable pattern of policymaking, and thus form a pluricentric mode of governance. This concept has been expanded upon in the past 20 years and the research now constitutes a key area of study within public administration.

networked Governance in Global Health

The research into governance networks up until this point has largely been focused on policy formation for a government; until recently the idea was not expanded to an international focus. David Fidler began supporting the concept of using networks as a means of governance in global health, which he called networked governance.2 He explains that while global health is currently on the political agenda, that could easily change, and so health governance must extend to non-state actors in order to ensure global health issues are being dealt with. As well, he contends it must be done without a framework, as he believes controlling the more powerful NGOs, such as the Gates Foundation, with one

Abstract

networked governance as a method of global health governance has emerged due to the increasing presence of non-state actors and the difficult nature of governing the wide variety of global health actors. it provides an opportunity for self-governance of all players through the formation of networks, allowing for priority setting and effective use of resources. it theoretically addresses many of the challenges currently faced in global health, including the coordination of actors and the effective use of resources. Whether this would occur in implementation, however, remains to be seen. difficulty in implementation is clear, as there are barriers to effective collaboration, including competition amongst players and the time cost in developing networks. As well, there is little accountability and transparency within networks, which would make it difficult to measure results and avoid corruption with this form of governance.

106 << Networked Governance

addressed and who has the skills to best deal with the issue. Thus, organizations such as the WHO will continue to play a leading role in areas where they have experienced success, such as pandemic management, but will allow other actors to lead for issues such as pharmaceutical funding and child health.4 The nature of networks is that they are ever-changing and constantly being remodeled to address need, by including new players or losing them, and by creating smaller sub-networks to deal with more specific issues.5 This allows for the shifting of power needed to successfully manage the wide variety of problems involved in global health.

overarching player would be incredibly difficult.3 This idea has gained popularity as a potential solution to govern the ever-expanding field of players in global health. In this sense, the proposal calls for networks made of multiple actors to coordinate their efforts in dealing with global health issues. Actors in such networks can include any groups involved in the management of global health issues, including governments, private organizations, the World Health Organization (WHO) and individual donors. Using a horizontal form of governance, such as networked governance, to manage the wide variety of groups involved has potential to succeed in the current landscape. Networked governance removes central leadership, allowing for leadership to shift between different players depending on the specific issue being

Conferences similar to the World Health Assembly will be

crucial in developing networked governance.

Eric Bridiers with the US Mission Geneva, 2010.


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nGiven the increase in actors and private funding sources, the WHO no longer has the influence needed to fill this role. While some proposals may suggest shifting to another leading institution or providing the WHO with more power, networked governance shifts away from this idea and instead allows for a variety of leaders within various sub-networks.3

As previously described, the main goal of networked governance is to allow for the collective focus of various stakeholders, all aiming to accomplish certain global health goals.7 Instead of constructing a new framework, committee or governing body, networked governance focuses on the utilization of the current connections between stakeholders and the active development of new relationships.6 Networked governance is often viewed as a response to the failure of downstream implementation,7 defined as the ability of a single authority to maintain governance among all involved actors, in the current global health landscape. The great deal of specialized knowledge involved in global health combined with the already complex infrastructure renders hierarchal governance structures useless for governing global health.7 It would be impossible to effectively organize all of the stakeholders involved vertically, with a single organization

The proposed reform fits with the cycle of governance in global health from strong leadership to diffused leadership, and is less structured than other reforms and proposals, such as the proposed Framework Convention on Global Health.6 Networked governance involves facilitating the formation and maintenance of relationships, but does not have a chosen leader or framework that must be followed. While there will be leadership within networks, there is no chosen leader other members must follow, and leadership can shift from one actor to another as circumstances require. This is in sharp contrast to the early days of the WHO when the organization was the leading global health institution and guided the actions of all involved actors.4

Melinda Gates, co-chair of the Gates Foundation, with

Ban Ki-Moon, UN Secretary General, at a press conference.

Women Deliver, 2010.



• Use of networks as non-hierarchal governance between global health actors

• Administration • Time needed to develop network • Opportunities to collaborate

• Networks of communica-tion • Conferences • Literature concerning networks

• Inter-related networks of varying sizes tackling varying problems

• Established yet still dynamic networks, permanent normal operations

• Willingness of actors to participate in networks

table 1: Key elements of networked Governance


of global health leadership. It is often argued that the WHO should be responsible for the governance of global health actors.9 The organization’s normative authority drawing from membership of 193 countries makes it a rational decision that the WHO be the primary global health governing body. However, to date the organization has been unable to fulfil such a role, due perhaps to the fact that vertical organization is simply ineffective in the global health landscape. The adoption of networked governance would eliminate the need for the WHO to be responsible for sole governance of the global health sphere. The WHO may instead operate as a central body responsible for the administration of the main network, as well as facilitation of the activities of member organizations in their efforts to achieve network goals.

effectively Harnessing energy, Resources and creativity

Another serious challenge present in the global health community due to a lack of governance is the inability to effectively harness the available energy, resources and creativity.9 There is a great deal of specialized

managing all tasks of governance, as there are simply too many different focuses and goals. Networked governance provides a feasible alternative.


The current global health landscape faces various challenges in the realm of global health governance. As a proposal, networked governance directly addresses many of these challenges. The most obvious is that of a lack








• Leader-ship divided among actors in separate networks

• Allows for the involvement of varying actors, thus maximizing resource use

• Networks provide com-munication link, facilitating coordination

• N/A • Actors fund and prioritize initiatives associated with their networks

• WHO takes primary administra-tive role, maintaining transparency

table 2: How networked Governance Addresses Six Grand challenges in Global Health Governance

A woman on her cellphone while

selling vegetables in Bangkok, Thailand.



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ngovernance to openly share their resources, highlighting an obvious weakness of the proposal.

the coordination of Key Actors and organizations

There is also a lack of collaboration and coordination between various stakeholders.9 The current global health landscape possesses resources meant solely to facilitate communication, such as conferences and publications. However, these methods of communication lack the absolute participation necessary to effectively coordinate a large number of global health actors. This lack of coordination then makes it difficult for different organizations to initiate and sustain effective collaboration. When participating through an effective network, various actors will be able to form relationships with organizations expressing

knowledge and skill available in the global health arena, but lack of communication between stakeholders makes it nearly impossible to harness all these skills. The implementation of networked governance may foster additional communication and thus allow for the appropriate use of available resources. When a diverse group of stakeholders are able to collectively discuss global health strategies they may also be able to effectively align their individual resources. This alignment then prevents counterproductive overlap of programs, which would otherwise be a waste of valuable resources.8 Furthermore, in a network that operates effectively, stakeholders are able to develop trust and are thus more willing to share resources.6 Although this situation would be ideal, there exists no evidence to support the view that global health actors will become confident enough in the effectiveness of networked

If actors are involved in initiatives they strongly support, then the “lowest common denominator” outcome can be avoided.

Michael Kooiman, 2007.


Funding and Priority Setting

When considering collaboration, one cannot ignore the important role of funding. It is often argued that networked governance will be unable to effectively control funding and priority setting due to the hesitance of involved parties to participate in funding.10 However, when effective communication is established in a network, involved actors become committed to the process.8 If all

similar desires and goals.8 This is an inherent strength associated with networks, as they allow like-minded organizations to communicate, and prevent unnecessary coordination among actors with different goals. This will allow for collaboration, which will lead to the sharing of resources and ultimately the effective implementation of new programs and initiatives.

A man making repairs at the

Soon U Ponya Shin Pagoda

in the ancient city of Sagaing,

Myanmar.Steven J. Hoffman, 2009.


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ntraditional governance models, there is no need for all the actors involved in the global health network to focus on the same priority. Instead the network will allow stakeholders expressing similar priorities to coordinate themselves and allow for effective collaboration.7 For example, if a certain organization is not interested in the funding of AIDS research, they need not participate, but other actors that are interested in this initiative can harness the network as a means of communicating with other interested parties. In addition, as actors will only participate in initiatives they fully support, the issue of the “least common denominator outcomes” will effectively be eliminated.8 This issue arises when all stakeholders, whether they are interested in an initiative or not, are forced to reach a consensus. This process then results in all involved actors agreeing on the most minimal intervention.8 However, when operating through a network there is no need for every member to reach a consensus; it is only necessary for the involved members to agree on an initiative and often, as they are all aiming for similar goals, consensus will be far more easily reached.

Feasibility

The greatest strength of networked governance lies in its feasibility and practicality for implementation. Unlike other proposals, networked governance

actors feel heard and valued in a network, they are more likely to participate, and that participation should extend into funding. The effective coordination and collaboration of stakeholders will ultimately lead to effective funding; each involved stakeholder will want to contribute what they can as they are truly committed to the particular program or initiative being funded. The increased communication and collaboration of involved global health actors will lead to the need for priority setting. It can be difficult to effectively set priorities through a networked governance setting as the involvement of varying actors can often make it difficult to make decisions, exposing a weakness of the proposal. However, unlike


networkedGovernance

• WHO responsible for imple-mentation • All actors affected

• Establish networks through active par-ticipation of actors

• Time consuming due to lack of direct leadership

• Lack of par-ticipation of actors • Competition between networks

• Actors unwilling to collabo-rate due to differing ideology

• Time costs lead to lack of action on time sensitive issues

table 3: implementation considerations for networked Governance

If actors do not work collaboratively and constructively, the networks

will not be successful.Scott Maxwell, 2007.


health actors to discuss issues and determine in which specific networks they desire membership. It is unclear as to who will host these conferences and therefore be responsible for the additional administrative burden. It is necessary that details such as this be clearly defined before networked governance can be effectively supported in the global health sphere.

The political feasibility of networked governance is another positive aspect of the proposal. Due to the non-binding nature of networked governance, stakeholders (state and otherwise) will be more likely to participate, as their presence will in no manner create a binding legal contract. As members of the network, actors are able to participate in whichever initiatives they wish to support, and have no commitment to initiatives which they do not wish to support. This then eliminates the worry many state-dependent actors have about becoming legally bound in a reform that reflects negatively upon their country or political party.

cost

In the application of networked governance, there would be issues associated with cost. While it is difficult to ascertain the monetary cost of a system such as networked governance, there are clear issues with the amount of time needed to make decisions and take action. Due to the lack of an overarching leader, there would not be one individual or group able to make decisions for everyone, and thus the process of creating policy within sub-networks can be slow, uncertain and time-consuming. Collaboration would need to be encouraged, potentially through face-to-face meetings and conferences, which can be expensive and time-consuming in terms of organization

does not require drastic reorganization of the current global health landscape. Instead it simply requires a shift in actions already undertaken by many involved actors. In terms of operational feasibility, the implementation of networked governance will likely require a central body to initially establish modes of communication. This can be initiated through the organization of conferences, allowing varying global

Effective funding ensures those who require healthcare the most

are effectively reached.khym54, 2007.


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nwhich is counterproductive in terms of creating functional networks.5 Doing this will require the full participation of all global health actors, so that networking and working collaboratively increases access to resources and funding. Creating a successful environment of networked governance will also reduce the overall work needed to tackle global health issues. This is because the most effective networks would grow in significance, as they would experience the most success, given that they have the best variety of skills and resources from multiple actors. Those networks that have significant skill and resource overlap would be less effective, and thus over time become less significant as they have less success.5 Therefore, networked governance would promote efficiency within networks. The lack of overlap in successful networks would

and participation. The actors involved would need to be committed to the idea of collaboration and working within a network, which may be difficult as the time delays mean that action, and thus results, will not come quickly. This lack of success may discourage participants and reduce the commitment to collaboration, so retaining participation will be a challenge with networked governance. Among global health actors, there are issues with competition rooted in a need for funding and recognition, and this may prevent groups from wanting to work together. While this is not an issue faced solely by networked governance, the lack of an overarching leader and frameworks would make dealing with conflict and competition difficult. A major challenge is simply overcoming the tendency of actors to want to work independently,

Members of NASHI, a Russian GONGO operating as a youth group.Lyalka, 2007.


conclusion

As all of the above challenges are addressed, it becomes obvious that networked governance provides a strong alternative to the current organization of global health actors. If networked governance is supported, issues of accountability, transparency, monitoring and evaluation will need to be addressed. The proposal does not clearly define who will be responsible for addressing any of these issues, making obvious the need for further research focused on the feasibility of networked governance in the global health sphere.

result in actors with similar abilities working in different networks, and thus ability is spread out among networks.

transparency and Accountability

There are other serious concerns with networked governance that would need to be addressed in order for it to be a successful model of governance. A major concern is that of transparency and documentation. Given the esoteric nature of the proposal, there would be difficulty in tracking the success of the networks in achieving their goals. The suggestion of having the WHO as a central facilitating organization does not solve this, as there would still be no accountability to the WHO. While it may be encouraged, the amount of effort required to document success and failure would be a deterrent. As well, there would need to be a framework by which to provide documentation in order for it to be the most useful, which is not in line with the core idea of the proposal. Unfortunately, in order for networked governance to succeed and have actors remain committed to fostering the networks, there will need to be evidence of success. Another concern is the inability to screen actors and their involvement in various networks. This means that groups such as government-operated NGOs (GONGOs) and business-operated NGOs (BONGOs), which attempt to control and manage issues with the intent to do what is best for that entity, will be in positions where they can heavily influence networks.11 The danger in this is that these organizations will place personal goals ahead of international global health goals when dealing with networks, and thus may influence networks to make decisions that are not ideal for the issue at hand.


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Key Messages

» Discussions concerning the reorganization of global health governance must include networked governance as a possible alternative to the current organization of global health actors.

» The formation of networks can be facilitated through the organization of conferences, publications and seminars - all underlined by a commitment to increase communication among varying players in the global health sphere.

» Involved actors must recognize that networks will allow for the communication of ideas and merging of resources, eliminating the overlap of programs and unnecessary waste of resources.

» Further research should be supported as it is crucial to understand the direct implications associated with supporting networked governance in the global health sphere before this organizational method is implemented.

References1 Torfing J & Sorenson E. Theories of democratic network governance. Palgrace Macmillan; 2006.2 Fidler, DP. Architecture amidst anarchy: global health’s quest for governance. Global Health Governance. 2007;1(1).3 United Kingdom House of Lords Intergovernmental Organisations Committee. Chapter 3: International health:

the institutional labyrinth. Select committee on intergovernmental organisations first report. 2008.4 Birn AE. The stages of international (global) health: histories of success or successes of history? Global Public Health.

2009;4(1):50-68.5 Arya B, Lin ZJ. Understanding collaboration outcomes from an extended resource-based view perspective: the roles of

organizational characteristics, partner attributes, and network structures. J Manage. 2007;33(5):697-723.6 Gostin LO. A proposal for a framework convention on global health. J Int Economic Law. 2007;10(4):989-1008.7 Ansell C, Gash A. Collaborative governance in theory and practice. Journal of Public Administration Research and

Theory 18 (1): 543-571. 8 Provan KG, Kenis P. Modes of network governance: structure, management and effectiveness. Journal of Public

Administration Research and Theory 18 (1): 229-2529 Gostin LO, Mok EA. Grand challenges in global health governance. British Medical Bulletin. 2009; 90 (1); 7-18. 10 Crosby BC, Bryson JM. Integrative leadership and the creation and maintenance of cross-sector collaborations. The

Leadership Quarterly 21 (1): 211-230.11 Schott, B. GONGO Government Organized Non-Governmental Organization. New York Times. 2010 Oct 29;

Available from http://schott.blogs.nytimes.com/2010/10/29/go ngo/

UN General Assembly.Marcello Casal, 2007.

cHAPteR 9 GLoBAL Action netWoRKS

By Shruti Javali


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nintroduction

The term Global Action Network (GAN) refers to an emerging mechanism of global governance that was introduced by Waddell.1-4 GANs are multi-stakeholder arrangements connecting governments, businesses, civil society and community-based organizations on specific issues, aiming to fulfil existing gaps in governance by addressing sustainability issues of the common good, and fostering change at the global level.1-6 GANs address a broad spectrum of issues and thus vary greatly in size, organizational structure, mode of operation and desired outcome. In light of this, the following defining characteristics and competencies have been identified.

characteristics of GAns

GANs must have a global framework for action by maintaining an identity and action plan on every continent. This global presence is determined by their funding, which often has some asymmetry between the donor and the recipient; the stage of their development since establishing a globally active organization is a long-term initiative, the robustness and capacity of the stakeholders, and the individual membership strategies of the networks.1,2 GANs also aim for a paradigm shift from the current compartmentalization of global health problems by national governments to a holistic perspective that catalyzes the individual parts to be accountable to their issue-specific network.3

The basic operating strategy of GANs is to bring together all stakeholders concerned with a particular issue, develop a solution and implement it.2 This global system for issue-specific problem-solving requires independent yet interrelated elements

Abstract

Global Action networks (GAns) are multi-stakeholder networks linking governments, businesses, civil society and community-based organizations on specific issues, aiming to fill existing gaps in health governance. their global presence, organizational structure and mode of operation vary among the networks, but all GAns aim to keep their issues high on the global agenda. As part of a GAn, governments and inter-governmental organizations like the World Health organization become part of the many stakeholders in developing and implementing solutions to global health problems. GAns are thus uniquely equipped to address grand challenges to global health governance. However, GAns require a large change from the current status quo, which minimizes their political feasibility. they must also avoid further fragmentation due to issue-specific activities, but must network horizontally as well to develop a web of GAns. once GAns are established, their ability to collaborate and coordinate their activities at governance and grassroots levels makes them significant actors in global health.

118 << Global Action Networks

Bill Gates at TED.Steve Jurvetson, 2009.


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nacross borders.2 Within the Global Fund, for example, this is done through the country coordinating mechanism, a partnership of all the stakeholders involved at a national level. These country-level multi-stakeholder partnerships link the overarching Global Fund to local systems – from national and local governments to non-governmental organizations, academia and people living with the diseases.8 The model that the Global Fund has devised to address stakeholder representation and maintain legitimacy may not be relevant to another GAN, such as the World Water Council (WWC) for example, whose members are organizations united by their interest in water-related issues.9

Despite these varied definitional characteristics, the fundamental task of all GANs is to advocate for their issues to be put and kept on the global agenda. They often reframe their issues to obtain higher priority, or aim to add implementation capacities to existing regimes.2,4,7,10 In a GAN, implementation plans are collectively developed by stakeholders who have agreed upon their enforcement, with an inherent understanding of and commitment to further action.2 Thus, theoretically, GANS should be more effective than existing systems in translating knowledge into action.

to determine their individual roles in supporting the collective action plan.4 Thus, GANs preserve the distinct character of their individual elements as much as their composite identity.1

As a possible solution to current global health challenges, GANs redefine how global issues are governed. GANs are created with the expectation that they will participate in the redistribution and restructuring of power, and the reorganization of already interrelated organizations and people. This addresses systemic barriers by transforming the fundamental norms, organizational structures and decision-making processes.1-2

The initial role of GANs, therefore, is the creation and strengthening of its constituent organizations.

Given the number of organizations and stakeholders that must come together to form a GAN, unifying their differing decision-making processes requires an effective utilization of the core values of accountability, transparency and equity.1-3,7 A GAN such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, for example, demonstrates the problem of stakeholder representation and legitimacy.2,7 In order to maintain this legitimacy, GANs must be in constant dialogue with their stakeholders to preserve accountability



• Issue- specific, multi- stakeholder networks

• Research • Money and time to restructure governance system

• Greater clarity on outcomes • Collaboration among all key players

• Unifying all stakeholders involved in a given issue • New GANs

• Web of networks working in tandem across all sectors

• Stakeholders and governments willing to collaborate

table 1: Key elements of the Global Action networks Proposal


GAns as Solutions to Gaps in Global Health Governance

GANs have been put forward as a solution to the gaps in existing governance structures, i.e. lack of coordination between nation states, inter-governmental organizations (IGOs), NGOs, businesses and philanthropic organizations.1,2 These gaps also include a lack of sustainability in managing the global commons, the provision of public goods and international politics. In particular, the global identity of health problems such as environmental changes, poverty, pandemics and primary healthcare highlight the void that must be filled.1-2,5 The GANs pertaining to global health must thus address these gaps in the existing health governance structures.

Global health governance currently faces six ‘grand challenges’ that must be addressed.12,13 Essential characteristics for a solution to these challenges include a trans-national approach, a multi-sectoral perspective, and the inclusion of all key actors.12-15

The complexity and diversity of the types of GANs implies that outcomes vary from network to network, but in a general sense, GANs aim for outcomes at two levels. As an issue-specific umbrella organization, each GAN has a collective goal for all participating entities to buy into, usually identified as system organizing activities.1 This overarching goal must encompass the second level of outcomes, i.e. the individual objectives of participating organizations, thus encouraging a collective commitment to both levels of outcomes.1

This diverse collection of outcomes is problematic when attempting to assess the impact of GANs as governance mechanisms. For example, while the Global Fund might regard saving an estimated 4.9 million lives by the end of 2009 as a significant reduction in the global burden of tuberculosis, malaria and HIV, the Global Reporting Initiative regards impact as the 800 corporations using its framework.1,11 Most emerging GANs however, have not developed enough to measure the effects of their activities, a testament to GANs as an emerging identity.1,5








• Unifies actors in specific areas of global health

• Participation and solutions from multiple stakeholders on specified issues

• Could serve as coordination mechanism for actors involved in particular areas

• Could devel-op a GAN to concentrate efforts and resources on this issue

• Could be used as mechanism to attract funding or set priorities

• GANs could undertake accountability, monitoring and evaluation activities

table 2: How Global Action networks Address Six Grand challenges in Global Health Governance


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nworking towards the issue-specific mandate of universally accessible vaccines and immunization.17

Bringing together different stakeholders under the umbrella of an issue-specific network would decrease the potential for conflict in their activities by clarifying and incorporating individual roles under both levels of GANs’ outcomes.1,2 Further, the multi-stakeholder nature of GANs would unify the various actors who currently contribute to the fragmented and uncoordinated activities within global health.3 Being united in an issue-specific manner will thus allow funding agencies, non-state actors, and even non-health actors working towards health outcomes to integrate within the larger framework of the GAN.2,13 This change in approach to global health leadership is moving from a single spearheading organization to a network of leaders in global health. This paradigm shift will be largely dependent on the ability of such networks to promote order within the current chaotic landscape.

the need to harness the creativity, energy and resources for global health

The overwhelming proliferation of actors has given rise to a new level of wealth, creativity and innovation in developing health solutions. It is, however, important to question the effectiveness of such creativity and resources if they are simply thrust into the field without coordination.13 The resulting conflicts among stakeholders can undermine the advantages of the resources they have made available. These stakeholders include a majority of non-state actors whose roles and obligations are unclear in an area governed primarily by nation states and IGOs such as the United Nations and

GAns and Grand challenges in Global Health Governance


Leadership, particularly in an area that requires the coordination of multiple actors, is essential to global health and has been sorely inadequate. The WHO was established to exercise this leadership, but has failed to meet expectations despite its unique capacity to direct a host of powerful mechanisms such as treaties and regulations ratified and executed by national governments.13 This void in global health leadership presents a unique opportunity for the restructuring of global health governance. Given the multitude of actors and stakeholders from all sectors of society that currently contribute to global health, it is unlikely that the WHO – with its broad mandate to address all health issues – will be able to unite them.

On the other hand, if GANs were looked upon as future leaders in global health, leadership could be provided in an issue-specific manner. For example, as a GAN, the International Committee of the Red Cross could assume leadership for any and all activities globally that pertain to the protection of human life and dignity of victims of armed conflict. This could include, among others, the protection of civilians and provision of adequate healthcare to prisoners of war and refugees.16 Similarly, another GAN such as the GAVI Alliance could oversee access to immunization and vaccination on a global scale. Here, pharmaceutical companies (for research and provision of vaccines) and the WHO (for technical guidance) are stakeholders within the network,


Strategies to overcome this challenge must be a top priority to make GANs operational in channelling the creativity, energy and resources that are available in appropriate issue-specific streams. One major advantage of GANs in succeeding in this area is that they present an opportunity for the business sector, governments, NGOs and academia to collaborate from the infancy of ideas.1,2,3 This encourages discussion and debate to occur at the drawing-board stage rather than attempting to resolve conflicts later on during the enforcement of those ideas.

the lack of collaboration and coordination between multiple players

By definition, GANs bring together the multiple players and stakeholders involved in improving a particular global health issue. Ideally, an established GAN would subsume all issue-specific initiatives, programs and activities working both at the governance level (within national governments and IGOs) and at the ground level (local NGOs, clinics, public health agencies).1,2 The challenge at this point is with the internal governance structure of the GAN to mobilize the entire host of actors involved. This vertical coordination must then work in tandem with other GANs to develop an intricate web of directives, programs and activities that improve healthcare in a sustainable manner. Given the overlapping nature of most health problems today (e.g. the provision of vaccines in conflict ridden areas), it is highly likely that different GANs will need to coordinate their global governance strategies. This is in addition to establishing adequate internal governance structures and networks of stakeholders to implement the issue-specific governance directives in a top-down manner.1,3 If this

the WHO.13 State-central governance of resources through WHO regulations have been difficult to enforce; these include the WHO’s Global Strategy on Diet, Physical Activity and Health, enforced on the food industry in tandem with public health agencies, as well as the WHO’s Framework Convention of Tobacco Control between tobacco companies and national governments.13

One solution that has been suggested is to develop incentives for private industry and other non-state actors to participate in creating solutions for global health improvement. However, it is unlikely that this will fully address the issue of enforcement and compliance among stakeholders.13 In order to address this, GANs include resource-rich, non-state stakeholders in every aspect of global health problem-solving, from planning to implementation. As members of a GAN such as the Global Alliance for Improved Nutrition (GAIN), representatives of the food industry work with governments, NGOs and academia in the development and delivery of core nutrition programs such as National Food Fortification programs, among others. Through internal business alliances, awards and benefits offered to members, GAIN is able to work with the private industry to develop business models that ensure food is available to the neediest consumers at an affordable price.18

This is one example of how the not-for-profit, public good imperative representative of most NGOs, IGOs and networks working within global health has been aligned with the corporate strategies and economic imperatives of the business sector.3 Thus, the primary challenge is not a lack of resources, but rather the dissonance rampant in trying to implement those ideas.


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to create a GAN. At what point would the authority of one GAN end and the other begin? If food and nutrition is the focus of GAIN, and the Red Cross focuses on the protection of human life in conflict ridden areas, which of these should address malnutrition in a conflict zone? It is possible that unless strategic models are developed and implemented for the horizontal vs. vertical governance of GANs, the potential for such conflict might overshadow the actual health needs that must be addressed.13

balance is not achieved (e.g., if GANs focus too much on vertical governance as opposed to horizontal governance), increased fragmentation might be the result (i.e., more chaos).

The realization of an ideal GAN is impeded by the current definition of global health which includes an extremely diverse spectrum of issues from the economic, social and political realms of society.13 An additional challenge is the identification and definition of specific issues around which

U.S. Mission Quilt Challenge for Global Fund Exhibition.Eric Bridiers, 2009.


from governments and philanthropists on an issue-specific basis (as a GAN would do). This would address the problem of allocation, and since both donor and recipient governments would be stakeholders involved in the GAN, a stronger collaborative approach would be inherent to the GAN and thus implicitly understood by parties involved.3,13

However, the balance between vertical and horizontal governance and cooperation must again be reconciled if GANs are to be adopted as a governance mechanism. Issue-specific funding and priority-setting might provide a solution to the problem of national accountability, but conflict might arise among GANs competing for their share of the limited funds available.

the need for accountability, transparency, monitoring and evaluation

Accountability, transparency, monitoring and evaluation are identified in the literature as one of the defining characteristics of GANs. However without an enforcement mechanism, voluntary systems have proven to be unstable.1,2,13 Objectively, given that most GANs are still in their developmental stages, it is a good time for them to develop systems for monitoring and evaluation in tandem with an enforcement system.1,2 The nature of a GAN requires not only external accountability and transparency, but internal as well. The free flow of information among the stakeholders, whether from the business sector or governments, is integral to the basic functioning of a GAN.1,2 A number of existing GANs are working towards ensuring higher accountability and transparency among decision-makers. Some examples include the Global Reporting Initiative, which is a multi-stakeholder

the neglect of basic survival needs and health systems strengthening

Health systems strengthening has been ignored in ‘mainstream’ global health activity because it lacks the glamour of cutting-edge technological medicine or disaster relief and rescue.13 The WHO identified that health systems today drift from one short-term priority to the next, most of which are direct results of failing or absent primary healthcare.13 This highlights a void that favours GANs; since the limited global health resources are constantly diverted towards addressing issues with high media exposure and/or technological innovation, it is ideal for the development of a GAN that is solely focused upon health systems strengthening and meeting basic survival needs. Such a network could unite and coordinate all organizations working towards the same overarching goal, perhaps even including other GANs with a vested interest in health systems strengthening among its many stakeholders.1-3

the issue of funding and priority setting

Skewed funding and miscommunication at local, national and international levels is a major challenge, especially when working with limited resources as is the case in global health.13 A common problem in addressing the lack of funding is accountability; rich nations are not held accountable to their financial pledges to recipient states that require sufficient and stable health aid.13 The allocation of funding and resources by recipient countries and the influence of donor countries upon that allocation, are among other identified problems.13 When considered together, it is possible that perhaps funding should be sought


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nThe initial challenge will be legitimizing their role as global governance mechanisms to all stakeholders, governments, IGOs and academia.1,2 GANs represent an emerging field which entails new vocabulary, including the very classification of an organization as a GAN. A number of GANs identified within the literature in fact recognize themselves as NGOs, public- private partnerships or IGOs. The translation of this vocabulary from a theoretical model in an academic journal to implementable and marketable strategies will be a major challenge. Overcoming this challenge will be time-consuming and require a drastic change on the part of most stakeholders involved in global health. Some organizations that exemplify the characteristics of a GAN will find this transition simpler than others that might require major restructuring.

The second level of change that must occur for GANs to be effectively implemented is the creation of the larger network of GANs. Without this larger network, individual GANs are likely to focus only on vertical governance and problem-solving, resulting in even more fragmentation and chaos.

Establishing GANs as effective global health governance mechanisms is a long-term initiative that is highly dependent on the paradigm shift in global health

system encouraging open dialogue and collaboration in the reporting of credible corporate performance information; and Transparency International, which works with governments, businesses and civil society against corruption.1

It is possible that a GAN works in an incentive based manner solely to ensure accountability and transparency among other GANs, and enforces systems of monitoring and evaluation. It is also likely that the unique approach of GANs working on an issue-specific basis would hold stakeholders more accountable than an umbrella organization such as the WHO. The difference is that the latter would hold governments accountable for their contributions to solving health problems across the board, whereas the former would require transparency and accountability on only one specific health concern.2,3,7

Feasibility and Practicality of GAns Being implemented

Currently, GANs are “prototyping, planning and building infrastructure for change.”1 While some GANs will be unable to overcome early developmental stage challenges, the GANs that will work towards realizing their potential face a number of challenges.1,2



• WHO & UN • National gov-ernments • Civil society • Businesses

• Establish institutional structures for GANs • Facilitate networking

• GAN Secretariats • Time for coordination

• Stakeholders unwilling to collaborate • Actors pursue own agendas

• Funders • National governments

• Increased fragmentation and conflict among networks

table 3: implementation considerations for the Global Action networks Proposal


conclusion

Nonetheless, the promise of sustainability, collaboration and innovation as drivers of global change make GANs a favourable alternative to the current chaos of the global health landscape. It is clear, however, that even if GANs do not evolve into dominant forces of global governance, they will not be insignificant within the realm of global health.1

problem-solving from a nation-based model to an issue-specific one. In addition, with the establishment of an effective GAN, the current authority of national governments might diminish, since they would be one among many stakeholders resolving a particular global issue. In short, the establishment of GANs as the primary governing mechanism for global health requires all stakeholders involved to rise above the individual, national and regional political agendas. This goal might be considered idealistic, and when considered with the other factors, significantly decrease the political viability of GANs as an effective global health governance solution.

Key Messages

» Global Action Networks (GANs) may be a solution to the current gaps in global health governance, but require a paradigm shift to occur before they can truly be effective.

» To support GANs, the global health community must change its focus from nation-based challenges to issue-based collective problem-solving.

» Governments, IGOs and non-state actors should redefine their modus operandi for increased coordination on an issue-specific basis.

» High start-up costs would need to be invested to establish GANs as the primary global health governance mechanism, but effective and established GANs are likely to be self-sufficient and self- sustaining.


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nReferences1 Waddell S, Khagram S. Multi-Stakeholder Global Networks: Emerging Systems for the Global Common Good. In:

Glasbergen P, Biermann F, Mol A, editors. Partnerships, Governance and Sustainable Development: Reflections on Theory and Practice. United Kingdon (UK): Edward Elgar Press; 2007. Chapter 12; p.261-287.

2 Waddell S, Khagram S. The Future of Global Action Networks: The Challenges and Potential. United States Agency for International Development (USAID); 2006 Aug. 21

3 Waddell S. Global Compact as a new organisational form: A global action network. In: Waddock S, MacIntosh M, Kell G, editors. Learning to Talk. United Kingdom (UK): Greanleaf Publishing; 2004. Chapter 20; 289-301.

4 Glasbergen P. Global action networks: Agents for collective action. Global Environmental Change. 2010; 20: 130-141.5 Waddell S. Realising Global Change: developing the tools; building the infrastructure. Journal of Corporate

Citizenship. 2007; 26: 69-84.6 iScale. Global Action Networks [Internet]. 2010 [cited 2010 Nov. 21]. Available from: http://www.scalingimpact.

net/gan7 Benner T, Reinicke W, Witte J.M. Multi-sectoral networks in global governance: Towards a pluralistic system of

accountability. Government and Opposition. 2004; 191-210.8 The Global Fund: To Fight AIDS, Tuberculosis and Malaria. Who we are [Internet]. 2010 [cited 2010 Dec. 15].

Available from: www.theglobalfund.org 9 World Water Council. Membership General Information [Internet]. 2010 [cited 2010 Dec. 15]. Available from:

www.worldwatercouncil.org 10 Sridhar D, Khagram S, Pang T. Are Existing Governance Structures Equipped to Deal with Today’s Global Health

Challenges - Towards Systematic Coherence in Scaling Up. Global Health Governance. 2009; 2(2): 1-25.11 The Global Fund. The Global Fund 2010: Innovation and Impact [Internet] 2010 March. [cited 2010 Dec.

15]. Available from: http://www.theglobalfund.org/documents/replenishment/2010/Global_Fund_2010_Innovation_and_Impact_en.pdf

12 Dodgson R, Lee K, Drager N. Global Health Governance: A Conceptual review. World Health Organization. 2002. 13 Gostin L, Mok E. Grand Challenges in global health governance. British Medical Bulletin. 2009; 90(1): 7-18.14 Khagram S, Ali S. Transnational Transformations: From Government Centric International Regimes to Multi-Actor,

Multi-Level Global Governance? In: Conca K et al, editors. Sustainable Global Governance. New York (NY): Routledge; 2008.

15 Khagram S. Possible Future Architectures of Global Governance: A Transnational Prospective/Perspective. Global Governance. 2006; 12 (1): 97-117.

16 ICRC. About the International Committee of the Red Cross [Internet]. 2010 Dec. 15 [cited 2010 Dec. 15]. Available from: www.icrc.org/eng/who-we-are/index.jsp

17 GAVI Alliance. Who we are [Internet]. 2010 [cited 2010 Dec. 15]. Available from: www.gavialliance.org/about/index.php

18 gain: Global Alliance for Improved Nutrition. About GAIN [Internet]. 2010 [cited 2010 Dec. 15]. Available from: www.gainhealth.org/about-gain

Gostin’s FCGH would also support health systems strengthening for the retention of increasingly valuable health care professionals in developing countries.

UK Department for International Development, 2009.

cHAPteR 10 FRAMeWoRK conVention on GLoBAL HeALtH

By Jennifer Edge and Cheryl Liu


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nintroduction

Presently, international health law suffers from numerous inadequacies including vague standards, ineffective monitoring and insufficient enforcement mechanisms. The few legal instruments available are historically, politically and structurally insufficient to lift countries out of perpetual states of extremely poor health.1 In response to this challenge, Lawrence Gostin proposed the Framework Convention on Global Health (FCGH) in 2007. This framework convention aims to enhance poor countries’ capabilities to develop and sustain basic healthcare needs and services through improved international cooperation on mutually agreed-upon binding obligations. Hence, the framework commits states to a set of economical and logistical targets, and fosters constructive engagement by private and charitable sectors.

Addressing Global Health needs

Currently, within global health there is a critical shortage of donor funds addressing basic survival needs; this remains the primary cause of common diseases and disability across the globe.1 These basic needs, laid out in international agreements such as the United Nations (UN) Millennium Development Goals (MDGs), include sanitation and sewage, pest control, clean air and water, diet and nutrition, tobacco reduction, essential medicines and vaccines, and well-functioning health systems. Furthermore, the UN Economic and Social Council (UNESC) states that survival needs are a core component of the right to health and include the provision of immunizations, essential medicines, food, potable water, sanitation, disease prevention and treatment, primary health care and

Abstract

in response to the current structural barriers in global health, the proposed Framework convention on Global Health (FcGH) offers a multi-sector, comprehensive, legally-binding approach to establishing stronger health systems in underdeveloped nations. this suggested bottom-up strategy to global governance prioritizes basic health needs and allows states to commit to obligations in a step-by-step manner. initial negotiations of the broad principles for global health governance would be followed by specific protocols on governance parameters in subsequent stages. if successfully implemented, the FcGH could support the Millennium development Goals and coordinate currently fragmented activities through the engagement of key stakeholders from public, private, and civil society at a focal point for global health leadership. Although the FcGH could offer several advantages over previous global health instruments, and has the potential to address each of the six grand challenges in global health governance, its idealistic nature, particularly with respect to rallying sustained political and financial support from high-income countries, detracts from its feasible realization.

130 << Framework Convention on Global Health

commitments in a step-by-step manner.1 The initial stage requires participating states to agree to the framework instrument through negotiating broad principles for global health governance. Thus, the key modalities would be established in the initial framework, with an approach for specific protocols on governance parameters to be developed in subsequent stages. These protocols would be organized by key components of the global health strategy to develop more detailed legal norms, structures and processes in achieving the objectives set forth in the original framework.

health education for those with lacking health systems.2 However, given that the legal obligation to “respect, protect and fulfil” the right to health currently falls at the state level, the duty of improving the health of the world’s most disadvantaged people has been left to national actors who often lack the means to do so.1

Key elements of the Proposed FcGH

The framework convention-protocol approach denotes the process of incremental regime development, allowing states to make

Gostin’s FCGH would strive to prioritize

child and maternal health

among other fundamental

health services.DFID - UK Department

for International Development, 2010.


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ncould establish fair terms of international cooperation based on mutually agreed-upon, legally-binding obligations of stakeholders.

It is recognized that capacity building in developing countries requires a stable commitment of resources over the long-term that is modest compared to existing commitments in other areas.1 The resources invested in the FCGH must be consistently directed toward genuinely effective interventions to meet basic healthcare needs. Actualizing the full potential of the proposed FCGH also requires setting priorities, coordinating efforts, fostering public-private partnerships, and helping poor countries take ownership of policies and programs in a transparent manner. Thus, successful implementation of the FCGH relies on the ability of stakeholders to commit to long-term financial investments in basic health systems strengthening, and the willingness to cooperate with each other through this legal mechanism.

the FcGH: Addressing Six Grand challenges in Global Health

challenge i: the lack of global health leadership

Given the current proliferation of overlapping and conflicting programs of governments and non-state actors in

The key elements that would contribute to the formation of FCGH’s core principles could include a mission statement and coordination mechanisms to establish common and fair grounds for cooperative efforts, while also setting stakeholder obligations and institutional structures. Methods for empirical monitoring, enforcement and ongoing scientific analysis to assess cost-effective health interventions to guide subsequent law-making protocols could also be devised. Although each of the suggested principles has been integrated either fully or in part in the priorities of numerous global health stakeholder agendas, the FCGH introduces a novel approach by creating a unified and coordinated legal framework for all these concepts.3

The FCGH could offer several advantages over previous international instruments for global health.1 In recognizing the ineffectiveness of top-down approaches to build infrastructure, the proposed FCGH attempts to strengthen multiple layers within and outside of the health field to allow for capacity development in multiple sectors. This might discourage political bottlenecks over debatable elements, and provides for the emergence of a comprehensive international governance regime following future long-term negotiations. Most importantly, as an international legal instrument it



• Unified and coordinated legal framework to build enduring health systems

• Steady monetary and human resources

• Interventions to address basic survival needs • Prioritizing/ coordinating efforts

• Nation-state agreement • Key modalities of framework established

• Enduring, effective health systems to meet basic survival health needs

• Long-term commitment of all key players • Attainable costs for implementation

table 1: Key elements of the Proposed FcGH


objectives, defining means and methods, and enabling interventions to take place among stakeholders. However, it would require the balancing of power dynamics and diverse interests among key players if it hopes to become a cohesive leadership entity for global health.

challenge ii: Harnessing the creativity, energy and resources for global health

In bringing actors from public, private and civil society sectors together in a structured manner, the proposed FCGH could create a venue for pooling the ideas, energy and resources available in the global health arena. The involvement of national governments ensures that state autonomy and interests are protected, while contributions from the private sector could greatly enhance scientific advancements for global health through innovative processes. Civil society members are capable of bringing cultural, grassroots know-how to the table and can influence protocols through their technical field experience with implementation. It is recognized that successful implementation of the FCTC is largely due to the involvement of NGOs shifting from being policy advocates to taking an active part in the development of models of legislation,5

global health, responses to global health challenges have been ad hoc and fragmented. A framework convention could create a focal point for global health leadership.1 Convening stakeholders to negotiate a set of broad principles for global health governance could allow leaders from different sectors of society to emerge within a global forum and participate in shaping the initial FCGH architecture. Conversely, the construction of a high-profile forum for global health stakeholders may increase competition and political interests among stakeholders for leadership positions, impeding progressive dialogue. In the subsequent protocols, detailed legal norms, structures and processes to achieve the objectives in the original framework can be progressively drawn out by utilizing actors’ technical expertise in given fields. The advent of the WHO’s Framework Convention for Tobacco Control (FCTC) in 2003 led to the development of new national and international training programs and leadership opportunities for regional organizations such as the Southeast Asia Tobacco Control Alliance in tackling the negative impacts of the tobacco industry.4 Similarly, using a convention-protocol approach, the FCGH could offer a forum capable of setting key

The provision of adequate

shelter is another basic

need to be addressed.

Deane J, 2007.


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health development. In the establishment of the Kyoto Protocol, some critics question if the “new institution” of the United Nations Framework Convention for Climate Change (UNFCCC) provided effective leadership, or whether it simply provided the opportunity for creative bargaining to take place among powerful nations.9 As new alliances formed on the basis of national economic interests in response to emissions reductions, Grubb noted: “For all the academic speculations about the decline of the nation-state in the era of economic globalization, the Kyoto Protocol is very much an agreement struck by governments…US dominance is striking.”10 Thus, even with a seat at the table, the potential contributions of civil society and the private sector may not be maximized.

challenge iii: coordinating key players

The framework convention could create an overarching umbrella structure for coordinating obligations and enhancing

implementation guidelines,6 capacity building and training of government officials,6-7 and being vocal contributors to the ongoing deliberations of the Conference of the Parties.8 Hence, bringing heads of state, the private sector and civil society members together under a FCGH could encourage each sector’s unique expertise to effectively converge in the formation of sustainable solutions to meet global health needs.

Despite this possibility, however, the highly structured nature of the FCGH may hinder the innovative capacities of private actors and NGOs. The legally-binding nature of the FCGH only holds governments accountable to their commitments, potentially giving more weight to state-centric preferences and strategies for global

Basic survival needs such as adequate food and crop yield are still threatened in

many developing countries.UK Department for International

Development, 2009.


easier said than done; accounting for the diverse interests among stakeholders may exacerbate the complex nature of collective agenda-setting and defining of mutually-agreeable goals. The FCGH could establish a Conference of Parties to take place at regular intervals to evaluate progress, assess compliance and develop plans for action. This would contribute to establishing relations between stakeholders and expand a shared outlook towards possible gains.3 It is important to note, however, that the purpose of the proposed FCGH’s convening of stakeholders to address global health needs closely resembles that of the existing World Health Assembly (WHA). A FCGH Conference of Parties would likely mimic the process used by the WHA when adopting the FCTC, which is perceived to have consisted of two main phases, the first involving initial brainstorming by a technical working group on the potential parties, principles and contents of a convention, and the second involving the establishment of an intergovernmental negotiating body to draft and negotiate the proposed FCTC and possible related protocols.11 Drawing from the FCTC experience, the FCGH could hold promise for bringing together multiple stakeholders to meet shared goals, but the tremendous cost associated with creating a forum that so closely resembles the existing WHA raises questions about its necessity.

challenge iV: Addressing basic survival needs and health systems strengthening

The FCGH takes a comprehensive approach to the provision of basic survival needs which is more adaptable to addressing the multi-sector issues of global health than issue-specific health laws. The proposed

collaborative efforts between multiple global health players. A FCGH could promote the creation of clear, concise and easily verifiable rules and goals that have been derived through negotiation early on in the convention stage, and continue to play an integral role in coordinating the protocols that follow. However, reaching global consensus on initial rules may be

Access to life-saving

antiretroviral drugs needs

to be made a priority.

UK Department for International Development,

2010.


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nin practice as states ultimately decide the content and goals to be addressed. Thus, while the proposed FCGH does well to target the major determinants of health, it would need to acquire substantial technical support and political consensus from the international community before actively pursuing its goals.

challenge V: the lack of funding and priority-setting in global health

While the exact costs of the proposed FCGH are unknown, the adoption of a legally-binding FCGH presents the challenge of obtaining enough funds to create, implement and enforce a comprehensive, sustainable regulatory regime for global health. The proposed FCGH’s single financing mechanism could contribute substantially towards the uniform management of global funding for health by aligning health aid with national priorities, simplifying bilateral aid relationships, avoiding aid conditionality, and fighting corruption.13 It also proposes setting achievable goals for global health spending as a proportion of Gross National Product (GNP), potentially generating funds for development. While encouraging,

FCGH establishes fundamental principles that strive to build sustainable health systems through the retention of trained health care professionals, development of surveillance strategies, and construction of laboratories for health systems research. While admirable, lessons learned from the Global Polio Eradication Initiative (GPEI) suggest that success depends on the creation of proven, technically-sound and operationally-feasible goals that have been demonstrated across a large geographic scale.12 Moreover, it is essential that international consensus be obtained at the highest level (in the case of the GPEI this was the WHA) and that political and financial support is sustained from wealthy nations.12 It’s important to note that consensus on the GPEI was only reached after poliomyelitis eradication was demonstrated in the Americas; thus, the FCGH could face obstacles in its mass comprehensive approach to global health systems strengthening if it lacks an evidence-based, universally supported method of feasible implementation. In addition, although the proposed FCGH explicitly calls for the prioritization of basic survival needs as listed in the MDGs, there is no guarantee that this would be maintained








• Creates focal point for multiple stakeholders in global health

• Engages nation-states, the private sector, and civil society

• Negotiable guiding principles and Conference of the Parties created

• Aims to provide basic survival needs for health systems strengthening

• Pinpoints areas of cost-effective investment and uses proportion of GNP

• WHO or new institution sets stan-dards, monitors progress, and mediates disputes

table 2: How the FcGH Addresses Six Grand challenges in Global Health Governance


enhance pressure for funding from signatory states and strengthen accountability mechanisms. Legal instruments also provide social movements with something to rally around, and encourage change that otherwise may not have been possible. For instance, African civil society groups such as the People’s Health Movement have cited the Abuja and Cuenca Declarations as lobbying tools for successfully holding governments accountable to their commitment of spending 15% of Gross Domestic Product on the health sector.14,15 In addition, although 20 industrialized countries are off-track on their Kyoto Protocol obligations, scholars agree that the UNFCCC has been responsible for bringing attention to the issue, shaming the reputations of governments who do not adhere to its provisions, and putting the necessary architecture in place for environmental protection. Essential monitoring and verification systems, carbon markets, technology transfer and funds for adaptation in climate change have all been mobilized by the Kyoto Protocol.16-18


While ambitious in its scope, the FCGH lacks political attractiveness, particularly

the massive budgetary requirements of the proposal would need legitimate priority-setting to take place within the global health agenda to avoid facing complications with donor funding and aid distribution.

challenge Vi: the need for accountability, transparency, monitoring and evaluation

The proposed FCGH could address the need for accountability and transparency through its legally-binding convention-protocol approach. By committing themselves to previously agreed-upon convention targets and principles, stakeholders could actively oblige to contribute their resources and knowledge to binding goals. Given that the aforementioned targets are mutually agreed-upon through negotiation at the convention phase, transparency among stakeholders is reinforced. The proposed FCGH suggests that the WHO or a newly created institution could set ongoing standards, monitor progress and mediate disputes throughout the implementation process. Although non-binding, ratified legal instruments can be used to progressively stimulate funding for global health by holding their governments accountable. The force of a binding FCGH, then, may actually

Providing essential vaccines and

medicines would be a priority under the

proposed FCGH.hdptcar, 2008.


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nhigh-income countries. Significantly, evidence from the Kyoto Protocol suggests that the loss of financially influential signatories (e.g., United States of America) compromises the integrity of treaties by “watering down” financial contributions and diminishing the impact of binding obligations, suggesting that a more politically flexible, non-binding instrument may draw more participation.16;20 However, if the FCGH were to incentivize ratification by high-income countries, evidence from

among high-income countries. Considering the current economic climate of austerity emphasized by the G20, the likelihood that national governments will be inclined to contribute to global health through a legally-binding instrument is questionable. Even if high-income countries sign onto to a FCGH, the lack of real punishments facing countries that fail to deliver suggests that commitments do not necessarily equate to tangible investments. This has been observed by actions of the G8 and its repeated failure to deliver on the Universal Access Pledge, among others.19 Additionally, the reputational cost associated with failing to meet the commitments of the FCGH discourages intensive commitment from

Prioritizing pest control on the global health agenda could reduce the

prevalence of insect-borne diseases like malaria.

Wahig, 1987.


high costs of implementation, the FCGH suffers from being overly optimistic in its assumption that high-income countries will actively engage in a legally-binding mechanism for global health. The FCGH proposal relies heavily on the goodwill of high-income countries to sign onto legally-binding commitments without considering the negative reputational implications for stakeholders that could result from failing to meet the demands of this reform.

Having said this, it is important not to dismiss the previous successful implementation of other convention-protocol approaches in global governance. In addition to the FCTC, a series of international environmental treaties serve as models for global health governance, such as the Vienna Convention for the Protection of the Ozone Layer. These framework conventions recognize that a collective effort is necessary to mitigate

legally-binding bilateral investment treaties suggests that a higher number of binding treaties raises the foreign direct investment that flows to a developing country from their high-income signatories.21 Still, while countries generally comply post-ratification, legally-binding instruments require global political support for joint solutions that is hard to achieve.20

Feasibility and Practicality in implementation

Despite the FCGH’s admirable prioritization of health systems strengthening, the proposed reform lacks feasibility and practicality in its method of implementation. In addition to its

Establishing medical research laboratories in low-income countries is

essential to sustaining functional health systems on the ground.

US Army Africa, 2010.


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nis exhaustive on both human resources and finances. Membership incentives and actors’ responsibilities within each step of the convention-protocol process are not addressed. Moreover, guidance for subsequent law-making processes would involve establishing content, methods and timetables to meet framework convention goals which currently remain unstructured. This bottom-up approach to global governance is innovative, but potentially shifts power dynamics to favour the agendas of grassroots organizations, threatening national autonomy. Experiences from the Paris Declaration and Accra Agenda for Action (AAA) suggest that transforming power relations between donors and recipient governments as well as between governments and civil society present challenging barriers to effective joint collaboration.22 Furthermore, the intended bottom-up approach contrasts with the FCGH’s aim to implement monitoring and enforcement mechanisms which would have to be arranged in a top-down structure.3

Also, the proposal fails to address the matter of duplication that exists between the FCGH’s Conference of Parties and the current work of the WHA. Member states of the WHA are granted the constitutional capacity to pass internationally, legally-binding conventions such as the FCTC, and

the threat that humans pose to health and the environment.1 While the FCGH acknowledges infectious diseases’ ability to pose threats to national health and security, high-income countries have typically only reacted to these threats in times of urgency and emergency (e.g., SARS and H1N1 outbreaks). The fact that global health issues are not perceived as ongoing, constant threats to international security limits the ability of the FCGH to motivate participation from high-income countries.

Creating a single fund for the FCGH poses problems for fiscal merging, fund allocation, and investment restructuring for current organizations in global health.3 Although the FCGH would target areas of cost-effective investment to achieve basic survival needs, create incentives and systems for scientific innovation for affordable vaccines and essential medicines, and set achievable goals for global health spending as a proportion of GNP, the cost of the proposed FCGH reform detracts from its feasible implementation at the present time. Moreover, given the legally-binding nature of the framework, high-income countries would likely be reluctant to ratify the FCGH and commit to its long-term financial obligations.

As stated previously, the proposed method of implementation for the FCGH



• Cooperative effort between nation-states, businesses, foundations, and civil society

• Commit stakehold-ers to obligations and create monitoring and en-forcement mecha-nisms

• Stable com-mitment of resources over long-term in single fund for global health

• Loss of momentum and key players; lack of consensus on contentious issues

• Unrealistic, idealistic, and politically impractical approach

• Threatens national autonomy; discourages participation of high-income countries

table 3: implementation considerations for the FcGH Proposal


on the most pressing global health issues. The FCGH might also create internal pressure for governments and others to actively participate in framework dialogue, an essential step in reaching international consensus.8 It could encourage states to commit to a set of targets, both economic and logistic, and dismantle barriers to constructive engagement by including private and charitable sectors. Inviting a broad spectrum of stakeholders from various institutions to a global forum may help in the search for sustainable solutions through the pooling of ideas, resources, and innovation. The FCGH could stimulate cooperative action on global health similar to the UNFCCC’s actions in addressing climate change; collective actions taken to mitigate global threats that impact population health across borders could serve to benefit everyone. The framework proposal stresses building long-term capacity for poor countries to take responsibility for their own health in collaboration with international governmental organizations, states, businesses, foundations and civil society. It allows developing countries to benefit from legally-binding commitments of high-income countries while targeting the major causes of common disease and disability in the world through addressing basic survival needs. Significantly, the development of the FCGH’s overarching and coherent framework for shared national and global responsibilities for health could result in the advent of concrete strategies for global health that extend beyond the MDGs.

The FCGH could also carry negative implications in its implementation. The proposed reform is unlikely to be a cure-all remedy for global health disparities; it cannot easily evade many of the seemingly engrained problems of global health

already possess the technical know-how of the WHO and its subcommittees to carry out evidence-informed policymaking. The proposal does not illustrate how the reform constitutes a mechanism novel enough to sufficiently supersede the current efforts of the WHA; implementing an entirely new legal instrument seems unnecessarily expensive to achieve the FCGH’s desired outcomes if similar effects could be derived from modifications to the current WHA structure.

implications of the Proposed FcGH

If adopted, the FCGH could hold positive implications for global health. The flexible, incremental nature of the convention-protocol strategy allows parties to establish politically feasible goals at the initial stage, saving more complex problems to be addressed in later protocols. Thus, this allows the international community to focus on a problem in a step-wise manner, avoiding potential political bottlenecks over contentious issues. A high-profile forum for normative discussion could help educate and persuade participating states, and influence public opinion, in favour of decisive action

A string of workshops in Calcutta

lines a stream contaminated with untreated

sewage.Lars Oh, 2006.


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FCTC, and the Paris Declaration and AAA) and suggest potential for the FCGH to address the basic survival needs of the world’s poorest populations.

conclusion

In recognizing the barriers to advancing global health, the proposed FCGH offers a unified, comprehensive and coordinated legally-binding approach to build enduring health systems in underdeveloped nations through targeting basic survival health needs. If successfully implemented, the FCGH could directly support the MDGs and coordinate currently fragmented activities by engaging a wide range of stakeholders at a focal point for global health leadership. The involvement of public, private and civil society interests could direct the many diverse resources and ideas for global health towards more

governance, particularly the domination of economically and politically powerful countries, strong resistance to creating obligations to transfer wealth, lack of trust in international legal regimes, and skepticism about the integrity and competency of governments in many of the poorest regions.1 The incremental nature of the framework convention structure may also result in a loss of momentum among participants as an extended, step-wise process may be viewed as long and drawn-out. Although it would convene a wide range of actors, it cannot ensure consensus on controversial issues.

Current critics of the FCGH argue that this type of agreement is unrealistic, idealistic and politically impossible.1 However, before dismissing this proposal, it is important to note that precedent-setting models of similar nature exist (e.g. International Health Regulations, the

Access to clean water and basic sanitation is still lacking in many low-income country communities.

UK Department for International Development, 2010.


collaborative efforts. On the contrary, multiple actors could also complicate the current nature of setting common goals for global governance. Before the FCGH reform could be successfully adopted, it would need to rally international political support for supra-national obligations to health (particularly among high-income countries), merge various streams of donor funding, and effectively establish an overseeing body to monitor progressive implementation of the FCGH. It would also need to incentivize high-income countries’ continual investment in basic health systems strengthening over the long term, and balance power relations and compromises between stakeholders.

Key Messages

» The proposed Framework Convention on Global Health (FCGH) offers a multi-sector, comprehensive and coordinated legally-binding approach to building enduring health systems through targeting basic healthcare needs and services

» The FCGH could address each of the six grand challenges in global health governance; however, the reform faces major political and structural obstacles to implementation, given its dependence on the sustained financial commitments of key players in high-income countries.

» The flexible, incremental nature of the convention-protocol approach could establish feasible goals at the initial stage, avoiding potential political bottlenecks over contentious issues, but may also result in a loss of momentum among participants as an extended, step-wise process could become long and drawn-out.

» If adopted, the FCGH could directly support the Millennium Development Goals by assembling stakeholders from public, private and civil society organizations at a focal point for global health leadership; however, it may not be able to evade many of the seemingly engrained problems of global health governance, particularly the domination of economically and politically powerful countries, and strong resistance to creating binding obligations to transfer wealth.


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nReferences1 Gostin L. Meeting the survival needs of the world’s least healthy people: A proposed model for global health governance.

The Journal of the American Medical Association 2007;298:225-228.2 United Nations. Committee on Economic, Social and Cultural Rights. The right to the highest attainable standard of

health (article 12 of the International Covenant on Economic, Social and Cultural Rights).Geneva: Economic and Social Council; 2000.

3 Balstad J, Røttingen JA. Examining the global health arena: Strengths and weaknesses of a convention approach to global health challenges. Oslo: Norwegian Knowledge Centre for the Health Services; 2010. Report No. 12–2010.

4 Wipfli H, Stillman F, Tamplin S, Luiza da Costa e Silva V, Yach D, Samet J. Achieving the Framework Convention on Tobacco Control’s potential by investing in national capacity. Tobacco Control. 2004;13:433–437.

5 Nathan R. Model legislation for tobacco control: a policy development and legislative drafting manual. Promotional Education. Paris: IUHPE; 2004.

6 Framework Convention Alliance. A guide to domestic implementation of the Framework Convention on Tobacco Control (FCTC). Geneva: 2006.

7 South East Asia Tobacco Control Alliance [homepage on the Internet]. Bangkok: South East Asia Tobacco Control Alliance. Available at: http://www.tobaccofreeasia.net/ (accessed November 14, 2010).

8 Sparks, M. Governance beyond governments: the role of NGOs in the implementation of the FCTC. Global Health Promotion 2010; 17(67): 67-72.

9 Andresen S, Agrawala S. Leaders, pushers and laggards in the making of the climate regime. Global Environmental Change. 2002; 12: 41-51.

10 Grubb M, Vrolijk C, Brack D. The Kyoto Protocol A Guide and Assessment, Royal Institute of International Affairs 1999.

11 Taylor A, Bettcher D. WHO Framework Convention on Tobacco Control: a global ‘‘good’’ for public health. Bulletin of the World Health Organization 2000;78(7):920-929.

12 Aylward, B. Global health goals: lessons from the worldwide effort to eradicate poliomyelitis. The Lancet 2003; 362: 909-914.

13 Ooms G. From the global AIDS response towards global health? A discussion paper: The Hélène de Beir foundation. The International Civil Society Support group; 2009.

14 Abuja declaration on HIV/AIDS, tuberculosis and other related infectious diseases. Organisation of African Unity; 2001.

15 PHA: People’s Health Assembly 2. The Cuenca Declaration. 2005.16 Adam, D. Analysis: has the Kyoto protocol worked? The Guardian 2008 Dec 8:10. 17 Philibert, C. Lessons from the Kyoto Protocol: implications for the future. International Review for Environmental

Strategies 2004;5(1):1-12. 18 Böhringer, C. The Kyoto Protocol: a review and perspectives. Mannheim: Centre for European Economic Research

(ZEW); 2003.Discussion Paper No. 03-61.19 Webster P. G8 summit: a final test of credibility. Canadian Medical Assocation Journal 2010;182(11):E499-E500. 20 Chopra M, Galbraith S, Darnton-Hill I. A global response to a global problem: the epidemic of overnutrition. Bulletin

of the World Health Organization 2002;80(12):952-958. 21 Neumayer E, Spess L. Do bilateral investment treaties increase foreign direct investment to developing countries? World

Development 2005;33(10):1567-1585.22 Hyden, G. After the Paris Declaration: Taking on the Issue of Power. Development Policy Review 2008;26(3):259-

274.

A WHO staff member vaccinates a child in Djibouti. The GPJ calls for the WHO to take a greater role in ensuring low-income nations have access to

essential medicines and vaccines.Jesse B. Awalt, 2009.

cHAPteR 11 GLoBAL PLAn FoR JuStice

By Katherine Georgious


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nintroduction

Over the last 20 years, funding for global health initiatives has increased dramatically, from US$5.6 billion in 1990 to $21.8 billion in 2007. Immense NGOs like the Bill and Melinda Gates Foundation have been created, as have national and multiparty initiatives like the President’s Emergency Plan For AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria, all in an effort to better improve global health. But with this increase in actors comes an increase in complications. The global health landscape now has an overabundance of players who lack accountability, often conflict in ideology, compete for funding, and cater to the interest of their donors rather than the communities they wish to serve.

Frustrated by this fragmented nature and desiring more drastic measures to shrink the gap between the rich and the poor, Gostin has proposed the Global Plan for Justice (GPJ). The GPJ is an initiative he hopes to bring to the World Health Assembly and have established by the WHO in collaboration with state and non-state actors.2 The goal of the GPJ would be to address three pressing issues in global health:

“(1) To ensure the fair allocation of essential vaccines and medicines, with particular attention to low- and middle-income countries in a public health emergency; (2) meet basic survival needs and create the conditions in which people can be healthy; and (3) help countries that will suffer most to adapt to the health impacts of climate change.”2

The GPJ would differ from current global health projects in how it is funded and

Abstract

if brought to fruition, the Global Plan for Justice (GPJ) has the potential to meet many of the six grand challenges in global health governance. the GPJ can aid in re-establishing the authority of the World Health organization (WHo) in the global health landscape by giving the WHo additional funding and invoking it as an authority figure in dealing with vaccinations, strengthening health systems, and addressing the adverse health effects of climate change. Furthermore, the GPJ can bring about greater coordination of different global health actors, and better prioritize funding with minimal influence from the socio-political agendas of donor nations. However, there are also concerns with investing in the GPJ. the GPJ could easily contribute to the already overbearing bureaucratic work recipient nations must undertake to ensure continued funding of their health programs. Also, its long-term feasibility is questionable, as its means of funding may be unrealistic.

146 << Global Plan for Justice

be administered by the WHO with the aforementioned goal of providing essential medicines to low-income nations, meeting basic survival needs, and aiding countries most affected by climate change. The GPJ would do this by providing a structured forum for all stakeholders, establishing effective norms, recommending pathways for cooperative action, and monitoring and evaluating compliance.2

This paper will provide an analysis of the GPJ’s potential effectiveness. Firstly, the GPJ will be examined in terms of its ability to address the six grand challenges in global health governance. The feasibility of the GPJ

administered. The GPJ would be funded by nations who commit to a voluntary contract to give the GPJ a certain percentage of their Gross National Income (GNI) per annum, based on their ability to pay.2 The percentage a nation devotes to the GPJ would be in addition to its other global development commitments, rather than in replacement of other projects. While the exact percentage given by each country would be negotiated under the guidance of the WHO, a realistic percentage proposed by the GPJ is 0.25% of a donor state’s GNI.2

Having received funding from individual nations, the GPJ would then

A rural village in The Gambia. Despite the long-term adverse effects of monocropping, peanut production is a key part of The Gambia’s current economy.

“Ikiwaner”, 2008.


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nabide by standards set by the WHO, and do work that the WHO considers a priority.

challenge 2: the need to harness the creativity, energy and resources for global health

In bringing together both state and non-state actors into greater participation with the WHO, the GPJ can succeed quite substantially in harnessing resources, creativity and energy for global health. Because the GPJ invokes the authority of the WHO, and has a very clear, narrow focus on the three issues it considers most prevalent in global health, it can effectively become the coordinating body for actors that address these three issues in the same way the Global Alliance for Vaccines and Immunization (GAVI) has become the coordinating body for global vaccination efforts. As such, the GPJ does have the potential to more efficiently make use of resources and energy devoted to providing essential medicines, providing basic survival needs, and combating the adverse effects of climate change.

While the GPJ can empower the WHO, and bring about better cohesion and coordination between many actors, its success in this field is limited. The six grand challenges of global health governance cite the need to harness the resources and energy

will then be discussed in an effort to better understand if and how the GDP should fit into the current global health landscape.

challenge 1: the lack of global health leadership

A great strength of the GPJ could be in its ability to harness the leadership power of the WHO, and enable the WHO to re-establish itself as the leader and coordinator of global health initiatives. The WHO is the sole international body with the constitutional mandate “to act as the directing and coordinating authority on international health work”. But with an estimated budget of $5.38 billion for 2011, the WHO does not have the financial backing to compete with every other actor, and for many years it has been unable to fulfil the leadership role it has been assigned.

By not only providing the WHO with additional funding, but also giving the WHO the authority to control, allocate and monitor these funds given to a variety of actors, the GPJ strengthens the WHO’s authority in the global health landscape, and provides said landscape with an authority figure it has been greatly lacking for decades. Being a voluntary contract further empowers the WHO, as nations and non-state actors that participate in the GPJ would be displaying their voluntary willingness to


the Global Plan for Justice

• The GPJ is a WHO-directed, compact to combat three pressing issues in global health

• Ratification by the WHA • % of a donor state’s GNI

• Grants to accomplish the three main goals of the GPJ

• Access to essential medicines • Access to basic survival needs

• Strengthened health systems • Sustainable agricultural practices

• Nations will voluntarily fund the GPJ • Will not be economically detrimental

table 1: Key elements of the Global Plan for Justice Proposal


international priorities. Health initiatives must compliment and not contradict other international policies. The WHO describes policy coherence as “crucial” to all global health initiatives.

However, the GPJ’s goal to mitigate the negative effects of climate change in developing nations could in fact worsen coordination efforts between global health actors and a developing nation’s economic and trade sectors. One of the GPJ’s environmental goals is a call for “the incorporation of land-use and agricultural mitigation, such as avoiding deforestation and degradation and pursuing sustainable agricultural practices”.2 But in avoiding deforestation and unsustainable agricultural practices, the GPJ’s goals could directly conflict with many nations’ economic interests.

For example, peanut production alone accounts for 6.6% of the GDP in Gambia. The monocropping of peanuts is extremely unfriendly to the environment as it requires vast expanses of clear-cut farmland, and worsens soil quality over time. However, in attempting to reduce monocropping to practise more sustainable farming, the GPJ can greatly hinder one of the largest sectors of Gambia’s economy, on at least a short-term basis. In conflicting with other

of the for-profit business sector. But being a WHO-based project severely limits the GPJ’s ability to do this. The WHO has very strict guidelines in dealing with the for-profit sector. Paragraph 15 of the WHO’s Guidelines on Working with the Private Sector to Achieve Health Outcomes states, “Funds may not be sought or accepted from enterprises that have a direct commercial interest in the outcome of the project toward which they would be contributing”. Furthermore, since no donors, not even nations, are given executive power on the GPJ for their donations, businesses would not have any say in how their funds are used, and as such would have little incentive to give funds or resources to the GPJ if and when permissible.

challenge 3: the lack of collaboration and coordination between multiple players

As previously mentioned, by invoking the leadership authority of the WHO, the GPJ could potentially provide better coordination and collaboration between various global health actors. But it is not only key for players within the global health sphere to be coordinated with one another; they must also be coordinated with other

1 2 3 4 5 6








• Will aide in re-establishing the WHO as the leader in the global health landscape

• Can harness the energy and resources of public, but not private actors

• May not effectively coordinate with non-health actors

• Addressing this need is one of the mandates of the GPJ

• Being a WHO-based program will enable effec-tive funding and priority setting

• The GPJ can ensure accountability, but may overburden recipient states

table 2: How the Global Plan for Justice Addresses Six Grand challenges in Global Health Governance


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nwithout the pressure to appease private donors, the GPJ can represent the best interest of the impoverished world without bias. As such, the GPJ can focus on strengthening health systems, and providing basic survival needs like water and basic sanitation, despite these initiatives being less appealing to donors and the general public.

challenge 5: the issue of funding and priority setting

The most important bias that the GPJ can avoid is the pressure to cater to the political agendas and national interests of donor states. Currently, many international partnerships find themselves prioritizing and funding the health needs of countries in which the donor countries have diplomatic interests. This problem is clearly evident in the Global Fund to Fight AIDS, Tuberculosis and Malaria. The Global Fund gives grants to qualifying nations on the basis of a successful application exhibiting need. Recently, the Global Fund has been criticized due to the fact that China is the fourth largest recipient of grants, having received almost $1 billion from the Global Fund since 2002. China has received triple the support that South Africa has, despite the fact that South Africa is one of the nations most severely affected by malaria, tuberculosis and AIDS in the world.14 There is a large discrepancy between which nations are being financially supported and which nations need aid the most. One of the major reasons China continues to receive grants is because the representatives of donor governments and recipient governments that are on the board of the Global Fund have “been mute or reluctant to oppose China…not wishing to provoke a reaction that impacts other diplomatic or political equities elsewhere.”14

sectors, the GPJ could potentially worsen the problem of the lack of collaboration between the many players on the international landscape.

challenge 4: the neglect of basic survival needs and health systems strengthening

If implemented, the most substantial and unique benefit of the GPJ may be its ability to ensure that beneficiaries of GPJ funds strengthen their health systems and work to bring about basic survival needs for their citizens. As previously mentioned, the strengthening of health systems is the second of the GPJ’s three goals.2 The GPJ can remain committed to this goal because it is administered by the Director-General and the WHO, and thus will be able to prioritize the needs of the poor over the interests of private donors.

The biases of those who implement a program can often negatively interfere with how it is run. For example, PEPFAR has been criticized for having policies that many feel place priority with AIDS prevention methods that align with conservative moral values, such as devoting a third of prevention funding to abstinence-only sex education, over initiatives that better address an AIDS-ridden community’s needs. Private NGOs like the Bill and Melinda Gates Foundation have also been criticized for bias, due to funding projects that interest the donors themselves and deal with high-profile diseases such as HIV/AIDS, rather than diseases that afflict a greater proportion of impoverished people like bacterial infections from unclean living conditions.

By being run by the international community, rather than by a single nation or a partnership of wealthy nations, and


officials. Bilateral donor channels often run outside Zambia’s efforts to coordinate a sector-wide approach to health systems development”. Because these ministries are overworked, they sometimes cannot meet all the deadlines and requirements that all their separate donors desire, and as such, lose funding. In a study of four ministries of health that partnered with GAVI, the application process for GAVI was generally viewed as too rapid and time-consuming for senior personnel in the collation of information, and it was found that the opportunity cost of partnering with GAVI was occasionally too high to have been worth pursuing. While the GPJ can potentially do a lot of good work in many nations, it will presumably exacerbate this already large problem.

Feasibility of the GPJ

While the method in which the GPJ is funded and administered allows for it to bring a lot of benefits to the international community, its feasibility is also a major cause for concern. Because it is a voluntary contract, it is unlikely that many countries would be willing to contribute to the GPJ, as it requires governments to relinquish all control as to how and where their money is used.

Countries want to pursue international projects that are relevant to their national interests. Half of American foreign aid focuses on Iraq, Afghanistan, Egypt, Israel, Colombia, Jordan and Pakistan, despite the fact that five of these nations are classified as middle-income rather than low-income countries. China funds many health-related initiatives in Africa, such as the sending of medical workers to post-conflict countries like Rwanda and Sierra Leone, to further their economic interests.18 By investing in

By receiving monetary assistance from wealthy nations without giving these nations authority to distribute these funds as they choose, the GPJ can receive the financial support of the developed world, without being muddled by its political problems. Since the GPJ does not give its donor states or partners executive power like the Global Fund does, it will not face the pressure to adhere to the interests of these donor states. As such, the GPJ would be able to fund and prioritize projects in nations that exhibit the most need, as opposed to projects that donor countries deem the most pressing, in locations that are of interest to one or many donor states.

challenge 6: the need for accountability, transparency, monitoring and evaluation

Like any other initiative, the GPJ will have bureaucratic measures to ensure that funds are distributed and used appropriately to bring about improvements in health. The WHO will be responsible for monitoring GPJ funds and ensuring the GPJ is accountable and transparent. Being a voluntary contract adds a large incentive for the GPJ to remain accountable to its donors, as nations that are dissatisfied with the GPJ can simply choose to withdraw their funding from the project.

But a major concern with the GPJ is that it will further add to the overwhelming burden of bureaucracy and the pressure to meet deadlines that is faced by developing nations. Many ministries of health often feel overburdened by the sheer magnitude of available aid. “Zambia for example, has major support from fifteen donor agencies, all of which demand separate reports, meetings and time from government


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nreferencing the WHO as the core body involved in a health commitment only increased compliance significantly for Japan and the United Kingdom. Furthermore, referencing other international bodies outside of the WHO was found to decrease compliance significantly for the United States.19 For the most part, the members of the G8 are disinterested in working with international bodies, and for the United

health, “China has built a network of trade, aid, and investment links with close to 50 African countries, and there has been a rush to buy up concessions to Africa’s natural resources”.

Various other countries are similarly interested in maintaining control over their global health efforts. In a study of factors that affect the G8’s compliance with their health commitments, it was found that

A water well in India. Access to basic survival needs, such as water, is one of the most pressing problems in the global health landscape, but is an issue that

receives minimal international attention.Ganesh Krishnamurthy, 2006.


little incentive, outside of a purely altruistic motive, for any donor nation to join the GPJ.

Gostin’s previous effort to bring about funding from high-income countries to projects that these nations cannot coordinate has not come to fruition. In 2007, Gostin proposed The Framework Convention on Global Health. The Framework Convention is a coordinating body that would require developed countries to relinquish a substantial amount of their autonomy in the global health landscape.

States, having to work with an international body served as a deterrent to complying with its G8 health commitments.

When nations do work with international organizations, they still retain some control over their funding. When nations donate to GAVI or the Global Fund, they are given representation on each respective project’s governing board, and thus they assist in determining what projects are funded. Without any representation on the governing board of the GPJ there is

An aerial view of Cairo, Egypt. Despite being a middle-income nation, Egypt is one of the seven highest recipients of American foreign aid.

Asandei Radu, 2007.


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nappealing to the altruism of the populations of wealthy states. Gostin says, “I’d need a lot of help from civil society — a bottom-up approach”23. By mobilizing the populations of these countries, Gostin hopes that he can move their government officials to action. However, based on the similarities between the GPJ and the Framework Convention, in that they both require an investment from developed nations without any immediate returns, it seems fairly unlikely that Gostin will find the monetary commitment he needs.

conclusion

The GPJ has a lot of potential to greatly impact the global health landscape. The GPJ can bring much needed financial backing and international sway back to the WHO, which in turn could lead to better priority setting and cohesion amongst other health actors. Because the GPJ would operate without the influence of private actors or its donor states, it would further be able to coordinate projects that directly assist those who need it the most. But this lack of influence that donor states have on the GPJ is also the major hindrance to its success. There is little incentive for states to donate to the GPJ, especially in comparison to pursuing their own global health projects or partnering with other international projects that would grant them some level of executive authority. However, if the GPJ can

As of 2010, it had not received the support from the developed world that it needed to become a reality.

Despite the fact that nations will not lose autonomy in signing to the GPJ, like they would with the Framework Convention, the Framework Convention is still a strong precedent to suggest there would be similar reluctance to the GPJ. Gostin is aware that funding the GPJ will be a struggle, stating in a 2009 interview that the GFJ is “always going to be a hard sell.” He echoed the sentiment of his critics, stating that an inherent problem with convincing nations to contribute to the GPJ is that, “Rich countries don’t want to give up what they’ve got. They don’t want to commit themselves, or lose sovereignty.”23

However, aswith other health initiatives, it is in a wealthy state’s national interest to fund the GPJ. An improvement in global health brings about increased security from infectious diseases and builds stronger diplomatic ties between the donor nation and the receiving nation, even if the donor nation is not permitted to decide which nation receives its funds. Furthermore, the monetary commitment required for the GPJ is paltry compared to many other expenses, such as the $1.5 trillion the international community spends annually on the military.2 Yet it can reap just as great, if not greater, rewards.

Gostin hopes that he can convince government officials to invest in the GPJ by



• The WHO • Donor nations • Recipient nations

• Support and ratification from the WHA

• Consistent, annual percentage of a donor nations GNI

• May not receive adequate funding

• Donor states that desire sovereignty on the international stage

• Overburdens recipient nations • Short-term hindrance to economy

table 3: implementation considerations for the Global Plan for Justice Proposal


find the financial and international backing it needs to get started, it can produce many positive, long-term, global health initiatives. The negative repercussions of additional bureaucracy, its inability to incorporate for-profit actors into its programs, and the potential short-term economic conflicts its initiatives may produce, are minor compared to the potential improvements the GPJ can give to the global health landscape.

Key Messages

» The GPJ’s greatest strength is in its potential to better prioritize funding and address the needs of developing nations than many other large international health initiatives.

» The GPJ can help return confidence and authority to the WHO.

» GPJ leaders must ensure that their policies do not conflict or compete with other international initiatives, particularly in the field of climate change.

» The proposed means of funding the GPJ is most likely unfeasible, and alternative methods should be discussed to ensure long-term sustainability.


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nReferences1 Editorial. Who runs global health? The Lancet 2009; 373(9681): 2083.2 Gostin L.O. Redressing the Unconscionable Health Gap: A Global Plan for Justice. Harvard Law & Policy Review

2010; 4: 271-294.3 WHO. The Constitution of The World Health Organization. July 22, 1946. Available at http://www.who.int/

governance/eb/who_constitution_en.pdf4 WHO. Draft Proposed Programme Budget 2010-2011. 2010. Available at http://apps.who.int/gb/ebwha/pdf_files/

MTSP-08-13-PPB-10-11/PPB-1en.pdf5 Taylor, A.L. Global Governance, International Health Law and WHO: Looking Towards the Future. Bulletin of the

World Health Organization 2002; 80(12): 975-80.6 Gostin, L.O., and E.A. Mok. 2009. Grand challenges in global health governance. British Medical Bulletin 90(1):

7-18.7 WHO. Guidelines on working with the private sector to achieve health outcomes. Nov 30, 2000. Available at: http://

apps.who.int/gb/archive/pdf_files/EB107/ee20.pdf.8 Commission on the Social Determinants of Health. Closing the gap in a generation: health equity through action on

the social determinants of health. The World Health Organization 2008.9 US Bureau of African Affairs. Background note: The Gambia. US State Department, 2010. Available at: http://www.

state.gov/r/pa/ei/bgn/5459.htm. Accessed Dec 10/2010. 10 Kuye R, Donham K, Marquez S, Sanderson W, Fuortes L, et. al. Agricultural health in the Gambia I: agricultural

practices and developments. Ann Agric Environ Med 2006; 13: 1–12.11 Check E. Criticism swells against AIDS program’s abstinence policy. Nature Medicine 2007;13(5):516. 12 Cohen J. The new world of global health. Science 2006; 311: 162-167.13 Brugha R., Donoghue M., Starling M., Ndubani P., Ssengooba F., Fernandes B., et al. The Global Fund: Managing

Great Expectations. The Lancet 2004; 364 (9428): 95-100. 14 Chow JC. China’s Billion-Dollar Aid Appetite 2009; Available at: http://www.fightingmalaria.org/news.

aspx?id=1480. Accessed Nov/16, 2010.15 Global Health Watch. Global Health Watch 2: An Alternative World Health Report. London and New York:

People’s Health Movement, Medact, Global Equity Gauge Alliance and Zed Books 2008. http://www.ghwatch.org/ghw2/ghw2pdf/ghw2.pdf

16 Brugha R., Starling M., and G. Walt. GAVI, the first steps: lessons for the Global Fund. The Lancet 2002; 359: 435- 438.

17 George J. Schieber et al., Financing Global Health: Mission Unaccomplished. Health Affairs 2007; 26 (4): 927.18 Zafar A. The Growing Relationship Between China and Sub-Saharan Africa: Macroeconomic, Trade, Investment, and

Aid Links. World Bank Research Observer 2007; 22(1): 103-130.19 Kirton, J., and J. Guebert. Canada’s G8 Global Health Diplomacy: Lessons for 2010. Canadian Foreign Policy 2010;

15(3): 85-105.20 The Global Fund Core Structures: Board. The Global Fund to Fight AIDS, Tuberculosis, and Malaria 2010.

Available at: http://www.theglobalfund.org/en/board/. Accessed Nov 16/2010. 21 Innovative Partnership. The Global Alliance for Vaccines and Immunisation 2010. Available at: http://www.

gavialliance.org/about/in_partnership/index.php. Accessed Dec 10/2010. 22 Gostin, L.O. Meeting the survival needs of the world’s least healthy people: a proposed model for global health

governance. Journal of the American Medical Association 2007; 298(2): 225-8.23 Clark H. ODA Is What Governments Want to Do at Their Whim. Inter Press Service 2009. Available at: http://

ipsnews.net/news.asp?idnews=49143. Accessed Nov/14, 2010.

View from the top of the World Health Organization’s Headquarters in Geneva, Switzerland. The World Health Organization’s Executive Board Meeting Room is seen on the far right and

the International Labour Organization’s Headquarters is in the distance.Steven J. Hoffman, 2005.

cHAPteR 12 iSSue-SPeciFic GLoBAL HeALtH LAWS

By Raman Kumar and Olivia Lee


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nBackground

Gostin and Taylor define global health law as a “field that encompasses the legal norms, processes and institutions needed to create the conditions for people throughout the world to attain the highest possible level of physical and mental health.”1 Although the domain of global health law primarily encompasses formal sources of public international law and formal subject of international law, in order to be an effective global health governance strategy global health laws must expand beyond these traditional confines. This paper examines whether this challenge can effectively be overcome using issue-specific health laws.

The International Health Regulations (IHR) are integral legal instruments that bind 194 countries, including all the member states of the WHO. The Framework Convention on Tobacco Control (FCTC), the first treaty adopted under article 19 of the WHO constitution,4 came into force on February 27, 2005. This treaty is the only international legal instrument designed to promote multilateral cooperation and national action to reduce the growth and spread of the global tobacco epidemic.3 Although there are still ongoing challenges in implementing these instruments,5 there continues to be interest in using an issue-specific global health law regime as exemplified by a proposed global administrative law6 and a proposal for a Framework Convention on Global Health.1,7

challenge 1: the Lack of Global Health Leadership

Issue-specific health laws could potentially fill the void in global health governance if used effectively as a governance tool by the WHO. The WHO is a natural leader to

Abstract

Relying on issue-specific global health laws to govern global health would promote the World Health organization (WHo) as a strong international health leader and as a platform for treaty negotiations. Such a system could only be effective if the WHo had punitive powers and dispute resolution mechanisms like the World trade organization. Since issue-specific law involves a multiplicity of players, it could harness creativity by drawing on many ideas. Since issue-specific laws are consensus-based, they are effective in coordinating different players. on the other hand, issue-specific laws often have skewed priorities because small groups of nations tend to drive laws based on narrow interests. they would be unlikely to address comprehensive issues like basic survival needs, but could ensure accountability and transparency through mandatory impact evaluations. issue-specific laws help address some of the grand challenges in global health governance, but seem less likely to address others. they are a viable option for enhancing current global health governance.

158 << Issue-Specific Global Health Laws

This streamlined, goal-directed governance structure has been successful in the past with the FCTC11, and the International Code of Marketing of Breast-milk Substitutes16. The WHO’s active role in facilitating negotiations and setting goals allowed for the successful passage of these issue-specific laws. Thus, this streamlined coordination would allow the WHO to emerge as a stronger leader in global health governance.

A major challenge to the WHO’s authority as a global health leader is its

facilitate discussion on issue-specific health law because it brings together 193 member states.1 The WHO could serve as a platform for negotiating issue-specific law between these states, and adopt a leadership position by establishing frameworks for laws based on clearly defined goals. Under an issue-specific global health governance regime, the WHO would be vital in coordinating member states in establishing laws based on commonly shared goals, and in providing expertise and technical skill to governments to help shape effective policies.

Smoking any tobacco product, %

female*.Emilfaro, 2009.

Smoking any tobacco product, %

male*.Emilfaro, 2009.


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ndebate. For example, in 2001 the United States effectively blocked the United Nations General Assembly motion to ban reproductive cloning, as it did not ban stem cell research.14 Thus, an issue-specific health law regime could establish effective global health leadership in the form of a World Health Organization equipped with the punitive powers of the WTO, but would continue to face challenges to its authority from powerful nations with differing health interests.

challenge 2: the need to Harness creativity and Resources for Global Health

An issue-specific global health governance regime would effectively mobilize resources, as it is often in response to crises where there is broad consensus for action. Since the treaties would be clearly defined in their mandate and scope, national governments, NGOs and other international actors may be more inclined to provide funding. Past experience has shown that focusing on one issue, such as linking chronic disease to tobacco, has stimulated the passage of issue-specific laws like the Framework Convention on Tobacco Control.11 Due to the consensus-

current inability to effectively enforce global health laws.1 In order for an issue-specific regime to provide effective leadership, the WHA would need to authorize the WHO to adopt the same punitive powers as the World Trade Organization (WTO). The WTO has the power to approve sanctions against various member states, but has also established dispute resolution tools.1 In contrast, international health treaties lack any substantive mechanism of enforcement that ensures compliance. Under an issue-specific global health law regime, nations could apply sanctions, whether trade or otherwise, to other nations that failed to meet their obligations after securing authorization from the WHO. Providing the WHO with these administrative powers would significantly bolster its authority and leadership potential, but at the same time faces the challenge of convincing member states to forego some level of sovereignty.

Furthermore, an issue-specific regime could not change the fact that powerful actors external to the WHO, such as the United States, would be able to drive or block certain issues and thus dominate the global health agenda. This is especially relevant as we look towards issues of biotechnology, which are at the forefront of contemporary health policy



• Governance based on targeted, specific health treaties among states and key non-state actors

• States give financial resources to finance laws based on ability

• Targeted global health legislation • Support by the WHO

• Establishing the WHO as the platform for treaty negotiations

• Incremental but effective, specific global health laws

• WHO has enforcement powers • Laws have universal support

table 1: Key elements of the Proposal for issue-Specific Global Health Laws


every law is negotiated individually, a multiplicity of actors would be involved in the negotiation process. While on the negative side this runs the risk of creating a patchwork of laws, on the other hand this would potentially allow for the implementation of a variety of approaches. An issue-specific regime could include NGOs and other non-state actors in the policy formation process, thus triggering greater creativity in global health governance.

Therefore, an issue-specific regime has the potential for effectively overcoming this grand challenge because of its ability to mobilize resources through broad consensus, and its further ability to stimulate creativity by involving many players in policy formation.

challenge 3: Lack of coordination Between Multiple Players

The December 2010 UN General Assembly on Global Health and Foreign Policy stressed the continued need for coordination and coherence at the national and international levels to enhance the

based and voluntary nature of issue-specific health laws, an issue-specific regime is well positioned to secure resources for the laws that pass, since in order to pass, those laws would have to secure broad support.

Furthermore, an issue-specific regime would increase creativity in overcoming global health challenges. The structure of this regime would be such that, since

1 2 3 4 5 6 Global Health

LeadershipHarnessing creativity, energy and Resources






• The WHO would serve as an effective global health leader, and platform for negotiations.

• Effective in mobilizing resources and creativity due to many participants.

• Would bolster the WHO’s role as an effective coordinator of multiple national players.

• Unable to compre-hensively address systemic issues. Patchwork problem.

• Priorities are skewed due to consensus-based and voluntary nature.

• The WHO could advocate for the implementation of mandatory impact evaluations.

table 2: How issue-Specific Global Health Laws Address Six challenges in Global Health Governance

United Nations General Assembly Meeting.

Marcello Casal JR/ABr, 2007.


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nchallenge 4: neglect of basic survival needs and health systems strengthening (HSS)

Issue-specific laws are, by nature, narrowly targeted toward certain goals, and thereby often limited in scope and mandate.14 The dual challenges of survival needs and health systems strengthening are highly complex, as they apply to many different sectors of society, including the economy, political institutions and national infrastructure. Addressing these challenges would involve many different forms of law, such as human rights and tax law, and may need to address a broad range of ethical and moral issues such as limits on the patient’s right to health.11 While issue-specific laws can be tailored to address specific problems relevant to survival needs and health system strengthening, they are cumbersome in comprehensively addressing systemic issues.

effectiveness of health initiatives and partnerships. An issue-specific regime would provide an outlet for the WHO to coordinate a multiplicity of nations in forming global health laws. The WHO, with its strong mandate as a natural global health leader, would serve as an effective coordinator of the many nations and non-state actors. It would serve as the platform for negotiations by providing appropriate facilities and invaluable expertise. As discussed in Dentico’s proposal for an R&D Treaty, issue-specific health laws require a coalition of like-minded countries.12

Issue-specific laws have proved to be an effective way of coordinating countries because they generally focus on points of agreement due to their consensus-based and voluntary nature. Broad, complicated, controversial issues can be broken down into smaller issues and laws passed where there is consensus.

Indonesian children give a thumbs up

celebration of relief aid near the town of Glebruk, one of the towns struck by the

Tsunami.Elizabeth A. Edwards.


to incorporate these goals into every global health law so as to foster greater cohesiveness among the potential patchwork.

In order to specifically address survival needs and HSS, an issue-specific regime would obligate member states to commit a certain amount of resources, proportionate to their finances, to these critical challenges. The International Committee on Economic, Social and Cultural Rights’ (ICESCR’s) General Comment 14 provides a relevant model.13 It obligates member states to supply a certain level of finances, resources and technical skill in meeting survival needs worldwide.13 However, since the ICESCR only addresses survival needs, an issue-specific regime would use the ICESCR as a model for establishing broader treaties that commit national governments to addressing both survival needs and HSS.

Therefore, an issue-specific regime has the potential of overcoming this grand challenge by fostering a strong coordinating role for the WHO. However, it is more likely that it will be unable to comprehensively address systemic issues due to the patchwork nature of issue-specific law.

challenge 5: the issue of funding and priority setting

An issue-specific global health governance regime would only be able to effectively prioritize insofar as a sufficient number of member states recognized and pursued those priorities. Under an issue-specific regime, global health priorities are determined by a coalition of nations that drive certain treaties forward. These nations are typically those with sufficient resources and political clout to do so.1 This would pose a difficulty for prioritization in an issue-specific regime, as the goals of these actors are often based on narrow, local interests rather than global

Since most issue-specific laws would be negotiated on their own terms, often with different actors taking a leading role in shaping the law, an issue-specific regime risks creating a patchwork of conflicting and contradictory laws.5 This would cause severe problems in global health governance, as member states could justifiably disregard inconsistent laws. Furthermore, an issue-specific regime would lack a centralized body to provide a unifying vision for global health law. In an issue-specific regime, the WHO could somewhat mitigate this problem by taking a leadership role in guiding policy negotiations. It could provide policy expertise to member states to ensure that new laws do not conflict with those previously established, and advocate for laws based on best evidence. The WHO would greatly increase its normative role to address the lack of central vision, identifying shared goals of global health and identifying common themes. It would aim

Fresh tobacco – the production of which is now governed by the Framework Convention on Tobacco Control.

Sjschen.


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time.9 For example, the adoption of the International Treaty on Plant Genetics Resources was considered a significant accomplishment, but required seven years of negotiations in order to pass.12 By relying only on issue-specific global health laws, policymakers face the risk of creating a patchwork of laws that do not encourage working together cohesively to address priority areas. Many of the biotechnology laws in existence today either conflict or overlap with one another, as well as with other laws created by institutions such as the WTO.12

An issue-specific regime would typically favour the interests of more politically powerful and wealthy nations, as treaties are usually funded proportionate to income.16 Past trends have shown that laws are

health priorities.1 Since issue-specific laws are often driven by the narrow interests of a small coalition of countries, the priorities of these coalitions would have to align with global health priorities in order to allow an issue-specific regime to effectively overcome the grand challenges.

Moreover, issue-specific global health laws would often be unable to set priorities due to the consensus-based and voluntary nature of negotiations. Since any actor can easily withdraw from negotiations, issue-specific laws would often have to be drastically altered in order to accommodate all the participants. This allows a small minority of nations to skew the agenda by threatening to withdraw their support if their demands are not met. For example, in December 2001, the United Nations General Assembly asked its Sixth Committee to consider a ban on the reproductive cloning of human beings.13 This was opposed by the United States government, which demanded that the ban be extended to stem cells.13 The process was delayed indefinitely, as member states were unable to reach a satisfactory agreement. Even when states are able to successfully negotiate treaties without making large compromises that cripple effectiveness, the process is often so slow that the issue has significantly worsened in the mean



• WHO • States • Non-state actors

• WHO facilitates treaty negotiations • States ratify treaties and fund activities

• Finances and technical expertise to implement laws

• Patchwork of conflicting laws • Lack of priorities

• States or lobby groups that disagree with a proposal

• Survival needs neglected • Priorities skewed toward wealthier state interests

table 3: implementation considerations for issue-Specific Global Health Laws

Former President of the United States, George W. Bush addresses the United

Nations General Assembly.Chris Greenberg, 2008.


depend on the agreement reached by the particular countries or other actors involved in negotiating the law. The WHO, as the coordinator of negotiations, could play an essential role in advocating for mandatory impact evaluations. In most cases, the implementation of the law would differ based on the unique sociocultural and political context of each nation.15 The WHO could provide the necessary personnel, guidelines and technical expertise to national governments or private actors for carrying out impact evaluations. The willingness of governments of countries such as Mexico to adopt these evaluations indicates that mandatory evaluations are politically feasible and would be an important way of ensuring accountability, monitoring and evaluation under a global

generally skewed toward the interests of those nations providing the most funding.16 This is problematic for priority setting because the states that are affected most by disease, infection and poor health care are those that have the least resources and therefore the least political influence.12 Moreover, heavy political lobbying would skew priority setting. Since every law is negotiated independently, an issue-specific regime allows political actors much greater opportunity to exercise political influence in negotiations.10 For example, powerful nations could place political pressure or offer concessions in areas other than health to change their voting decision.

An issue-specific regime could somewhat mitigate the problems involved in priority setting with a strong WHO or other centralized body that uses its “bully pulpit” to pressure governments into actively pursuing global health priorities. It would do so by raising awareness and developing expertise on pressing health challenges, and clearly linking the health of populations in developing and developed countries in the public mind. Despite this, the consensus- and voluntary-based structure of issue-specific laws evokes doubts on the ability of an issue-specific regime to overcome this grand challenge.

challenge 6: need for accountability, transparency, monitoring and evaluation

Under a global health governance regime based on issue-specific law, each law could incorporate mandatory impact evaluations. These evaluations would inform the public about the effectiveness of global health policies. Since every law would be negotiated separately, the extent of evaluations would

Relates to the United States’ refusal to sign a cloning treaty based

on its lack of provisions against stem cells.

Nissim Benvenisty.


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ndispute settlement body. Past trends have shown that the principle of sovereignty has been considered key in international health treaty negotiations.1 Members of the WHA have not approved any legislation giving the WHO punitive powers over health negotiations.1 Furthermore, there has been little transparency in the establishment and implementation of international health treaties, as in the case of the FCTC.5 While the Convention called for stricter labelling requirements and excise taxes on cigarette products, many national governments, especially in Latin America, have failed to implement these rules.5 However, as globalization continues and health issues become increasingly internationalized, there has been a steady trend away from sovereignty in the international health arena.1

Therefore, an effective issue-specific regime would depend on the willingness of international actors to consent to a World Health Organization with administrative powers similar to that of the WTO. With this new administration in place, an issue-specific regime that uses mandatory impact evaluations would significantly increase accountability and transparency in international health law.

conclusion

An issue-specific global health governance regime could potentially address the six grand challenges with varying degrees of effectiveness. An issue-specific regime could promote the WHO as a strong international health leader, which would serve as a valuable platform for treaty negotiations. In order to be effective in an issue-specific regime, the WHO would need to be equipped with the same punitive powers and dispute resolution mechanisms as the WTO.

health governance regime based on issue-specific laws.15

In order to ensure accountability, the WHO would adopt similar punitive powers and dispute resolution mechanisms as the WTO. This would provide an important mechanism of holding governments accountable to international health agreements. In the case of high-level disagreements, there would be a dispute settlement body available similar to that of the WTO, where representatives from countries not involved in the dispute assess the case brought forth by various governments and determine a fair outcome. The mere threat of facing sanctions would encourage governments to more carefully evaluate their ability and willingness to meet the demands of certain policies before making a commitment.1

One challenge is whether member states would be willing to grant the WHO the authority to approve sanctions, and whether they would consent to participating in a

Ban Ki-moon, currently Secretary- General of the United Nations,

photographed when he was South Korea’s Minister of Foreign Affairs.

R. D. Ward.

166 << Health Impact Fund

survival needs and priority setting (#4 and #5), convincingly. Their real weakness lies in their inability to comprehensively address systemic issues, instead creating a patchwork of contradictory laws. As the global community continues to struggle in coordinating national and non-state actors and enforcing accountability, issue-specific laws will likely become an increasingly attractive option for global health governance.

This global health governance strategy could also stimulate creativity and harness resources in global health because it involves a multiplicity of actors and approaches in global health laws. Since issue-specific laws are consensus-based and voluntary, they are an effective means of coordinating different players. Despite this, issue-specific laws often have skewed priorities because of the ability of a small group of nations, or even a single nation, to derail treaty negotiations. An issue-specific regime could ensure accountability and transparency through mandatory impact evaluations in every law. Issue-specific laws fulfil all of the grand challenges, except meeting

Key Messages

» In order for issue-specific global health laws to function effectively as a global health governance regime, the (WHO) must work to establish itself as the primary coordinating body for international health law by serving as an inviting platform for treaty negotiations.

» The World Health Assembly (WHA) should authorize specific laws that would obligate member states to commit to a certain amount of resources, proportionate to income, designated for survival needs and health systems strengthening.

» In order to ensure accountability and transparency, WHO administrators must coordinate with member states and non-state actors in establishing impact evaluations as a standard element of global health law.

» The WHO should provide the expertise and resources necessary to enable member states to effectively monitor issue-specific global health laws.


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nReferences1 Taylor A, Gostin L.O. Global Health Law: A Definition and Grand Challenges. Public Health Ethics. 2008: 1(1):

53-63.2 Sridhar D, Khagram S, Pang T. Towards Systematic Coherence. Glob Health Gov. 2009: 2(2): 1-25. Available from:

http://www.ghgj.org3 Roemer R, Taylor A, Larivier J. Origins of the WHO Framework Convention on Tobacco Control. Am J Public

Health. 2005: 95(6):936-938. 4 The Health Assembly shall have authority to adopt conventions or agreements with respect to any matter within the

competence of the Organization. A two-thirds vote of the Health Assembly shall be required for the adoption of such conventions or agreements, which shall come into force for each Member when accepted by it in accordance with its constitutional process.

5 Editorial. Implementation of tobacco control policies proves hard to do. The Lancet. 2007: 369(9580): 21336 Chesterman S. Globalization rules: accountability, power, and the prospects for global administrative law. Glob

Health Gov. 2008: 14(1): 39-527 Gostin L.O. Meeting the survival needs of the world’s least health people: A proposed model for global health

governance. JAMA. 2007: 298(2): 225-228.8 Who runs global health? Lancet. 2009: 373(9681): 20839 Gostin L.O., Mok E.A. Grand challenges in global health governance. Br Med Bull. 2009: 90(1): 7-18.10 Cohen J. The new world of global health. Science. 2006: 311: 162-16711 Mugnusson R.S. Rethinking global health challenges: Towards a ‘global compact’ for reducing the burden of

chronic disease. Public Health. 2009: 123(3): 265-274.12 Dentico N, Ford N. The courage to change the rules: A proposal for an essential health R&D Treaty. PLo5

Medicine. 2005: 2(2): 96-9913 United Nations General Assembly. General Assembly Draft on global health and foreign policy. Resolution 65/27

(A/65/L.27). 2010 Dec 1. New York: United Nations.14 Taylor, A.L. Governing the Globalization of Public Health. American Society of Law, Medicine and Ethics. 2004:

500-508 15 Global Health Watch. Global health watch 2: An alternative world health report. London and New York: People’s

Health Movement, Medact, Global Equity Gauge Alliance and Zed Books; 2008. [cited 2010 Dec 15] Available from: http://www.ghwatch.org/ghw2/ghw2pdf/ghw2.pdf

16 Myres AW. International code of marketing of breast-milk substitutes. CMA. 1982:127(4):326.

Prior to TRIPs, hospitals such as this one in India were able to have access to low-cost generic drugs given the exclusion of drugs from its 1970 patent law.

Tinya Lin in 2009.

cHAPteR 13 HeALtH iMPAct Fund

By Tinya Lin


Background, History and Rationale

Providing access to pharmaceutical drugs in developing countries has remained a difficult topic to balance when coupled with the need for innovation incentives. Under the Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPs), member countries are required to accept the standards of intellectual property (IP) protection for any invention, including pharmaceuticals, for a term of typically 20 years.1 This is meant to remunerate the high costs of research and development (R&D) by providing the patentee power to temporarily monopolize their products and mark up prices while preventing copycat manufacturers from capturing dominant market share. However, this system is poorly equipped to incentivize innovations for less desirable economic markets such as those in the poorest nations which often carry the greatest disease burden.2 As a result, R&D for new drugs is seldom conducted to target diseases that plague the poor. Inaccessibility due to high drug prices further prevents innovators from optimizing their impact as there is currently little incentive to ensure the appropriate use of medication by consumers. This constitutes “the last mile problem”.3

The Health Impact Fund (HIF) is a plan to reform incentives for the R&D of new pharmaceutical drugs. It was first conceptualized theoretically by philosopher Thomas Pogge, who later formalized the details of this plan with economist Aidan Hollis in 2008. Innovators can choose to register a new drug with the HIF and receive payment from the fund based on their drug’s incremental impact on global disease burden.4 Given the incentive to sell as many products as possible to increase

Abstract

there are currently few incentives for the research and development (R&d) of pharmaceuticals targeting diseases that primarily affect the poor because this group cannot pay the typically high prices for patented medicines. the Health impact Fund (HiF) is a plan to reform incentives for new drug R&d by providing financial rewards to innovators proportional to the incremental impact of the drug on global disease burden. this essay assesses the plan’s capacity to meet the grand challenges facing global health governance. While the HiF will harness innovation and energy to global pharmaceutical needs by prioritizing drugs with the greatest health impact, the need for enduring funding and for an effective monitoring and evaluation system for each registered drug, presents significant obstacles to implementation.


and distribution. Secondly, the HIF will reward based on health impact, thus encouraging innovators to create and support the conditions for optimal drug benefit such as accessibility and appropriate use.5 The third component of reform will develop a fair and feasible allocation of the cost of the HIF to fund the reward mechanism.6

Responsibilities and obligations of Key Players

The administrative body that will be responsible for implementing the HIF will bear responsibility for the technical (e.g., setting protocols, frameworks, and determining health impact), assessment (e.g., assessment of each product and protocol), and auditing (e.g., confirming the accuracy of assessment and adherence to protocol) functions.3 As incentives are rewarded in direct proportion to health impact achieved, the assessment agency of the HIF will be responsible for examining the evidence collected to determine the incremental change of global disease burden. Given the large funding and high stakes for accurate health impact measurement, the audit process will need to be transparent and accountable. Once a firm registers their product with the HIF it will be the obligation of the administrative body to allocate the appropriate reward.

“health impact”, the selling price set by drug manufacturers will theoretically be as low as the long-term marginal cost of production.1

Key Players in the Health impact Fund

The HIF is meant to supplement, not replace, the current IP system as an optional alternative system, and will require the coordination of funders, multiple stakeholders and a large administrative body. A feasible means to finance the HIF is to obtain a commitment from countries to allocate a portion of gross national income per annum.3 Innovators will play a key role in deciding which products to register with the HIF. Furthermore, the task of coordinating the HIF will fall to an external agency, created for the sole purpose of administration. This secretariat will serve a crucial role in determining, assessing and auditing the mechanism of the HIF.

Scope of change

The HIF is meant to tackle the problems exacerbated by the IP system – lack of innovation, inaccessibility and the last mile problem – through three key components.3 First, drugs will be provided as a public good, eliminating the monopoly held by innovators under the IP system. This will increase financial accessibility as the competitive price for medicines is driven towards the marginal price of production


Health impact Fund

• Global fund to incentivize R&D by rewarding health impact of drugs

• $6 billion USD/yr • Administrative body • Health impact data

• Drugs sold at low cost • New drugs targeting diseases that affect poor

• New drug innovations • Affordable drugs • Monitoring data

• Global disease burden alleviation

• Ineffective current alternatives

table 1: Key elements of the Health impact Fund Proposal


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nIt is imperative for the HIF that funders adhere to an obligated, committed contribution schedule to ensure the availability of funds for the entire term of the HIF. The suggested commitment term for funders is 12 years, 3 with the reward term being 10 years.

Health impact Fund inputs

The greater the annual contribution to the fund, the less uncertainty innovators

Innovators will be responsible for obtaining market clearances and preauthorizing the HIF administrative body to do so if their claim is unsuccessful. Products are expected to be sold at no more than the marginal cost of production and distribution wherever needed.5 The HIF will also be preauthorized to sub-license patents to generic firms and hold the responsibility to do so if supply needs are not met.

The markets that exist in developing nations, who often carry the greatest disease burden, are unattractive to innovators who need to recoup R&D costs by raking in

profits from marked-up drug prices.Lucy Chen, 2009.


Thus, the HIF is meant to benefit innovators with patents for drugs with high global health impact but low profitability with the current IP system, by providing an incentive to commercialize their drugs. However, pharmaceutical industries have argued against the assumption that the current IP system causes lack of innovation, inaccessibility and the last mile problem, instead citing inadequate medical infrastructure in developing countries as the institutional driving force for these problems.7

will have when recouping R&D costs and the greater the incentive to utilize the HIF over the IP system. The suggested minimal annual contribution to the fund is about US$6 billion, about 0.01% of global income.3 However, administrative costs, such as assessing health impact, are expected to absorb about a tenth of the annual fund3.

An accurate and comprehensive monitoring and reporting system would be needed for each registered HIF drug. The assessment of health impact would require a large amount of data input, drawing on the resources of governments, insurers, NGOs, wholesalers, pharmacies, competitors and other stakeholders to measure drug distribution and consumer benefit.

Women selling bread at a border crossing between Vietnam and Cambodia.

Steven J. Hoffman, 2009.


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nGrand challenge 1: Lack of global health leadership

The HIF’s mandate does not include taking a leadership role to influence and coordinate multiple global players, and is limited to addressing the topic of drug innovations. Additionally, the lack of global health coordinating efforts can pose significant barriers to the development of a monitoring and evaluation system to determine health impact for registered products in the HIF. The HIF will thus not meet the challenge of creating global health leadership, and additionally be hindered by the lack thereof.

Grand challenge 2: need to harness creativity, energy and resources for global health

The HIF will provide an incentive for innovators to direct research, development and distribution of pharmaceutical drugs according to optimal global health benefit. As a result, the HIF may be highly effective at encouraging the appropriate private and public players to not only draw on creative innovations for global health, but also carrying them through to a tangible benefit as the reward will be directly dependent on medication performance.4

evidence-informed Analysis of Proposed Reform

Meeting the needs of the global health community

Currently there is little incentive to invest in medicines that will not bring significant profits to regain the R&D costs that have been invested. Pogge has stated the following as seven failings of the current IP system: (1) high prices due to the profit-maximizing price for drugs imposed by patentees who enjoy a market monopoly; (2) neglect of diseases affecting the poor given their unattractive market; (3) bias towards profitable ‘maintenance’ drugs; (4) wastefulness in IP litigation costs; (5) production of illegal counterfeited drugs which endanger health; (6) the need to increase sales volume causing excessive drug use and the production of “me-too” drugs; and (7) the “last-mile” problem where there is little incentive to ensure actual consumers benefit from products.8,9,2 The HIF was created to provide the incentives to tackle these problems. However, the extent to which the HIF can help meet other grand challenges in global health governance has yet to be assessed.10







Health impact Fund

• Will not take up leadership or coordination of players, but be affected by lack thereof

• Will incentivize research, development and distribu-tion of essential drugs

• Administration will increase coordination among market clearance and sublicensing

• Focuses on development and distribu-tion of essential medicines, not health systems

• Funds drugs based on priority of need, but will need enduring funding

• Will need to create rules for and implement monitoring and evaluation of health impact

table 2: How the Health impact Fund Addresses Six Grand challenges in Global Health Governance


companies when the innovator is unable to do so, and will also do so following the end of the reward term.3 Thus, the use of a specified coordinating body to tackle the administrative work and bureaucracy involved in these tasks is expected to increase the efficiency between the multiple players involved in the patenting, manufacturing and distribution of a drug.

Grand challenge 3: Lack of collaboration and coordination between multiple players

While the HIF’s primary goal does not include the effective partnerships and coordination of initiatives, the obligation of the innovator and the HIF administrative body to provide adequate supplies of the new drug globally will advance collaboration towards the goal of reducing disease burden through drug innovations. The administrative body of the HIF will hold responsibilities for obtaining market clearance and sub-licensing to generic

The socioeconomic disparity that exists, especially between developed

and developing nations, creates a problem for global drug accessibility.

Tinya Lin, 2009.


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nthe developing world. As a general fund for any patentable innovation, political and bureaucratic lobbying can be avoided as resources will be allocated towards global health impact, thus putting priority on global disease burden alleviation, not specific interventions.4 However, while the mandate of the HIF may align with health agendas of developing countries, the risk of inadequate funds as well as conflicting priorities between donors and recipients remain. Given the role of the administrative body to register and determine reward payment to innovations based on health impact, priority will likely remain on global disease burden reduction.3 However, central to the rationale for HIF funding is the assumption that it will be more cost-effective than current alternatives, such as traditional humanitarian programs providing subsidized drugs.11 Thus, while the HIF puts priority on tackling the current problem that little R&D is invested in orphan diseases,6 whether this approach will be more effective for this goal will need to be verified empirically.11

Grand challenge 6: need for accountability, transparency, monitoring and evaluation

Given the large amount of funding that will be under the control of the HIF’s administrative body, measures to ensure accountability and transparency can be

Grand challenge 4: neglect of basic survival needs and health system strengthening

The HIF incentivizes drugs with the greatest health impact, which includes the essential medications for diseases plaguing developing countries. As the markets of developing countries tend to be an unattractive economic target for new drug R&D and distribution, the HIF will contribute to basic survival needs by incentivizing innovators to align research priorities with effectiveness in reducing global disease burden for a high impact effect.4 Health system strengthening may also occur as an indirect consequence of innovators wishing to optimize health impact (through addressing the last mile problem,) and who are thus willing to invest in the proper distribution and delivery of drugs for effective treatment. On the other hand, the HIF would only encourage the development of certain types of healthcare delivery infrastructure in developing countries. To strengthen a country’s entire national health system, funding for existing public infrastructure would be necessary, not just the mobilization of innovators and multinational drug companies.11

Grand challenges 5: issue of funding and priority setting

The HIF was created for the purpose of addressing the lack of funding and priority setting in drug development and access for


Health impact Fund

•Govern-ments •Pharmaceu-tical industry •Administra-tive body

•Create administra-tion •Global funding •Metrics

•$6 billion/yr •Start-up of administra-tive body •Monitoring & evaluation

•Poor funding •Reluctant firms •Assessment difficulty

•Governments as funders

•Aid money as profit •Potential for gaming and corruption

table 3: implementation considerations for the Health impact Fund Proposal


when it determines the reward amount. As a direct consequence to this, a significant obstacle to implementing the HIF would be the need to create mechanisms, such as an international health information network to prevent corporate gaming as firms may resort to exaggerating reported health impact to increase reward size.4,12 Therefore, accountability, transparency, monitoring and evaluation remain critical for the implementation of the HIF, and it can be expected that successful implementation may improve the current status quo, as measures will be taken to guarantee the improvement of these elements.

expected to spill over in global health governance. The shear amount of data required to accurately assess health impact will put the HIF as one of the largest assessment agencies in the world.3 This may also create pressure on other agencies, especially in the private sector, to do the same. Monitoring and evaluation of drug products for clinical effectiveness can also advance medical prescriptions and scientific progress on therapeutic benefits.6 Given the dependence on a monitoring system to determine health impact, great effort will be put into tracking the development and distribution of registered drugs, especially

Monitoring and evaluation of health impact will present as a huge obstacle to implementing the HIF, as both the healthcare infrastructure and vital registration systems remain largely underdeveloped in

nations with the most valuable data, such as in low-income countries.Tinya Lin, 2009.


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nmonetary reward for each increment remains vague.4 Additionally, the resources to monitor and evaluate these variables remain largely underdeveloped, and will require large start-up costs to the HIF.

As well, the dependency of the HIF to attract innovators is strained by the need for long-term commitments by funders. Innovators will be highly unlikely to invest in R&D unless there is reliable assurance of long-term funding, which will largely depend on the commitments of governments.4 It will be difficult to predict the conditions that would create a strong enough incentive for innovators to invest in the R&D of new drugs tailored to this artificial market, especially given the decentralization of funding sources.7

other implications and outcomes

An additional positive outcome that can result from implementing the HIF is the wealth of data collected from monitoring and evaluation of registered drugs, which may have other useful implications beyond determining the size of the HIF reward. In addition to the value of the data in contributing to an evidence-based approach to therapeutic drug benefits, the monitoring and evaluation infrastructure that will be put in place can spillover and strengthen capacity to monitor other health outcomes. However, the collection and the quality of data may also depend on the availability of existing infrastructure, where areas with the most valuable information for assessing health impact would likely be those with the weakest system to rely on, such as in low-income countries.13


The HIF is politically attractive compared to other proposed solutions to essential medicines inaccessibility as it does not threaten the existing IP system, but presents an alternative for innovators who normally would not benefit from their patents. Multinational drug companies can lend their support without compromising their obligation to maximize profits for their shareholders, and will be more likely to trust its funding commitments as it is long term and backed by international governments.4 However, the suggested US$6 billion commitment per annum for 12 years will stall governments from pledging funds given the long-term commitment and difficult exit strategies. The international support needed by the HIF is also a political problem as multinational support will be difficult without wider international cooperation.12 For example, aggregating and formalizing networks for assessment of health impact data at the global level will remain difficult without commitment from national governments to adhere to monitoring and evaluation, especially in countries where vital registration system are the weakest.6,12

the Feasibility of the Health impact Fund

While the HIF presents a realistic mechanism for rewarding innovators for addressing global needs,12 a significant barrier to the feasibility of the HIF is the ability to accurately and comprehensively measure health impact. While the suggested use of Quality-Adjusted Life Years (QALYs) as a metric of health impact is practical given its current use in health system assessments, details such as the ability to measure incremental change in disease burden from an eligible drug and the appropriate


conclusion

The HIF presents an efficient mechanism to reward health impact to expand access and innovation, that can theoretically overcome some major challenges in the current IP system.4 However, due to the current lack of necessary structures, such as a vital registration systems and health infrastructure in many developing countries, it will be difficult to take the HIF from theory to practice without the empirical grounds for evidence which is currently lacking.11

Key Messages

» Lack of innovation, inaccessibility and the “last mile” problem are issues that have been exacerbated with the current intellectual property (IP) system, thus requiring a new incentive system for the research and development of drugs primarily targeting developing countries which often carry the greatest disease burden.

» The Health Impact Fund (HIF) can harness creativity, energy and resources for global health, and shift the focus to medications with the greatest potential to impact world health needs, while also strengthening monitoring and evaluation systems in countries, without threatening the existing IP system.

» The need for long-term funding provided by multiple governments will be critical in providing innovators with a strong assurance of adequate incentive to commit to the R&D of new drugs tailored for the HIF proposal.

» Accurate monitoring and evaluation of drug products will be difficult given the weak infrastructure often present in developing countries, although it may encourage health system strengthening as tracking drug benefits will be necessary for determining rewards.


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nReferences1 Hollis A. The Health Impact Fund: A Useful Supplement to the Patent System? Public Health Ethics. 2008 Jul

1;1(2):124-133. 2 Pogge T. The Health Impact Fund: boosting pharmaceutical innovation without obstructing free access. Cambridge

Quarterly of Healthcare Ethics. 2009;18(1):78-86. 3 Hollis A, Pogge T. The Health Impact Fund: Making New Medicines Accessible for All. Incentives for Global Health;

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Solutions. Public Health Ethics. 2008 Jul 1;1(2):110 -123. 5 Banerjee A, Pogge T. The Health impact Fund: a potential solution to inequity in global drug access. Indian Journal of

Medical Ethics. 2010;7(4):240-243. 6 Sonderholm J. A Reform Proposal in Need of Reform: A Critique of Thomas Pogge’s Proposal for How to Incentivize

Research and Development of Essential Drugs. Public Health Ethics. 2009 7;3(2):167-177. 7 Barton JH. TRIPS and the global pharmaceutical market. Health Affairs. 2004;23(3):146-154. 8 Pogge T. Healthcare Reform that works for the U.S. and for the World’s Poor. Global Health Governance. 2008 Fall /

Spring 2009;2(2):1-16. 9 Banerjee A, Hollis A, Pogge T. The Health Impact Fund: incentives for improving access to medicines. Lancet. 2010 Jan

9;375(9709):166-169. 10 Gostin LO. Grand challenges in global health governance. British Medical Bulletin. 2009 Jun 1;90(1):7-18. 11 Päivänsalo V. Responsibilities for Global Health: The Efficiency of the Health Impact Fund? Public Health Ethics.

2009 Apr 1;2(1):100 -104. 12 Faunce TA, Nasu H. Three Proposals for Rewarding Novel Health Technologies Benefiting People Living in Poverty. A

Comparative Analysis of Prize Funds, Health Impact Funds and a Cost-Effectiveness/Competitive Tender Treaty. Public Health Ethics. 2008 Jul;1(2):146-153.

13 Sonderholm J. Intellectual property rights and the TRIPS agreement: an overview of ethical problems and some proposed solutions. Policy Research Working Paper Series. 2010.

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