GDIA RESIDENTIAL SCHOOL RABAT, 20 – 24 MARCH 2016 Global Health Governance Dr Michael Jennings

WHO’ S DEFINITION OF GOVERNANCE FOR HEALTH Governance is one of the four functions of a health system: 1. Financing 2. Creating & managing resources 3. Service delivery 4. ‘Stewardship’ “Stewardship is the last of the four health systems functions … and is arguably the most important. It ranks above and differs from the others … for one outstanding reason: the ultimate responsibility for the overall performance of a country’s health system must always lie with the government. Stewardship not only influences the other functions, it makes possible the attainment of each health system goal: improving health, responding to the legitimate expectations of the population, and fairness of contribution.” [WHO World Health Report 2000, 119]

IS HEALTH GOVERNANCE A LIMITED CONCEPT ? Stewardship is about: – Policy – Influence – Information It does not disaggregate roles within govt at national level Does not really engage with role of local govt / admin under decentralisation Scope is limited: does not consider issues of state vs market, state vs non-state actors, etc Focuses on governance at the national level: but what about the international? Ignores non-health global policies & structures & their impact on health

THE PROBLEM OF GLOBAL HEALTH GOVERNANCE: 1979: Charles Pannenborg listed the challenges facing global health: – Lack of coordination between donors, recipient countries & NGOs – Lack of coordination between WHO, World Bank, other UNOs & international organisations – Lack of national health plans, and plans that do not provide for donor coordination – Donor neglect of recurrent expenditures – Donor's short-term perspectives – Health aid tied to donor interests / policies Sound familiar?

WHO IS IN CHARGE ? LACK OF GLOBAL LEADERSHIP WHO is supposed to be the pre-eminent global health institution: – Direct international health policy in collaboration with UN agencies, governments & others in the promotion of health – Assist governments in strengthening health services – Provide assistance & aid in emergencies – Establish & maintain epidemiological & statistical services It has an extensive mandate: – “to promote, in cooperation with other specialised agencies where necessary, the improvement of nutrition, housing, sanitation, recreation, economic or working conditions and other aspects of environmental hygiene.” It has the power to propose agreements, conventions & regulations

SO IS THE WHO IN CHARGE ? The World Bank spends more on health than the WHO Donor bilateral programmes also increasingly bypass the WHO – E.g. US PEPFAR funding for HIV WHO has increasingly been side-lined by new global health organisations (to whom donors channel increasingly large sums of money) – E.g. Global Fund, GAVI, Gates Fdn, etc

WHY IS WHO SO WEAK ? Its institutional authority is limited: – It cannot force governments to act – The regional office system undermines central authority Its funding model is weak: – Donors have cut down on fixed contributions (which go to the general budget) – & increased extra-budgetary contributions (which they can direct the use of) It is a ‘soft-power’ institution: – Each member state has an equal vote – World Bank, Global Fund, GAVI, etc are dominated by donors

FRAGMENTATION 2010: est. 40 bilateral donors; 26 UN agencies; 20 global & regional funds; 90 global health initiatives: – Rival agendas & priorities – Poor cooperation & coordination between them – Replication of funding streams, efforts, systems, etc – Lack of unified platforms increase transaction costs for donors & recipient govts. – Increased workloads for recipient govts / orgs.

SHORT-TERMISM Focus on immediate results rather than long-term capacity building Rapid switching of focus as new issues rise up the global agenda Disease-specific focus New initiatives often begun before funding stream has been established Too little integration with national-health systems

LACK OF TRANSPARENCY & ACCOUNTABILITY Donor interests can shape national health priorities: – MDG process – Donor influence over priorities Little pressure on donors to report their activities report to govts – Tanzania health minister: only discovered donors were funding the same NGO they were at an external conference – How can govts. plan, allocate & prioritise resources if they do not know how much money is coming in and where it is going?

IMPACT ON NATIONAL HEALTH SYSTEMS Vertical delivery systems – Create parallel structures, services & systems – Focus on specific diseases rather than broader health – Ignore SDH & other contextual issues which are important – Skews national health budgets – Skews wages / research funding to areas of donor priority Are national systems being undermined by current GHG architecture?

EBOLA & ZIKA: IMPLICATIONS FOR GHG ? Delayed Responses Af Regional Office did not hold regional health summit on Ebola for 3 months Brazilian MoH & PAHO responded quickly to evidence of potential link between Zika virus and microcephaly – (Though WHO headquarters did not respond until 3 months later) Surveillance Ebola outbreak occurred in areas with weak monitoring & surveillance capacity Brazil’s live-birth information system gave ‘real-time’ data, allowing changes to be rapidly detected

EBOLA & ZIKA CONT. Competing interests Different sections within WHO & global health community are competing for the same resources Decl. an International Health Regulation Advisory Body brings resources & builds empires Role of regional offices Who should lead in regional emergencies? If WHO is so structure- bound & subject to will of donors, can regional office be more effective? Is the answer more power to the regional offices?

CONCLUSIONS GHG is essential for improving public health: Setting global health priorities Support national health systems Allow for rapid response to crises Ensure democratic, transparent & accountable decision-making Ensuring global health remains the priority for health actors Looking back to the list of governance problems in 1979 – how far have we moved since then ?