GDIA RESIDENTIAL SCHOOL
LONDON, 23 – 27 MARCH 2015
Global Health Governance
Dr Michael Jennings
WHAT IS GOVERNANCE FOR HEALTH ?
 Julio Frenk: LIST model of health governance:
1.
Technologies: interventions to maintain health
2.
Systems design: processes through which resources are deployed
3.
Institutions: mechanisms through which policy & strategy is enacted
4.
Leadership: vision, direction, knowledge, values from the top down
 WHO sees governance as 1 of the 4 functions of a health system:
1.
Financing
2.
Creating & managing resources
3.
Service delivery
4.
‘Stewardship’
WHO & STEWARDSHIP
(WORLD HEALTH REPORT, 2000)
 “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.”
 Stewardship is about:
– Policy
– Influence
– Information
IS STEWARDSHIP A LIMITED PERSPECTIVE ?
 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
GLOBAL HEALTH GOVERNANCE
 The institutions at local, national, regional & international levels
 The funding mechanisms at each level
 Policy-making & implementation at each level
 Issues of power: who is making decisions, setting priorities, etc
 Dynamics between states, markets, & civil society
 International rules & regulations, & their impact on health
GLOBAL HEALTH CHALLENGES – AS SEEN IN
1979 (PANNENBORG)
 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 functions:
– Collaborate 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
 The understanding of its role is wide:
– “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
WHO IS IN CHARGE ? IT ISN’T THE WHO
 The World Bank spends more on health than the WHO
 WHO has increasingly been sidelined by new global health
organisations (to whom donors channel increasingly large sums of
money)
– E.g. Global Fund, GAVI, Gates Fdn, etc
 Donor bilateral programmes also increasingly bypass the WHO
– E.g. US PEPFAR funding for HIV
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?
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 ?