Reimagining the Future of Global Health Initiatives
Article Number: 3
A biased report that should be challenged
The Reimagining of the Future of Global Health Initiatives is a study report by five universities. It is evidently written from recipient countries’ perspectives and shows a lack of understanding of the rationale for GHI policies and procedures and what actually happens. The report’s recommendations fail to take account of: (a) what needs to be done at national level to permit changes at the GHI level; and (b) the inherent dangers of the proposals.
This article is about a recent (but undated) report of a study entitled ‘Reimagining the Future of Global Health Initiatives’ by a consortium of five universities. The study focused on six GHIs: the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund); Gavi, the Vaccine Alliance; the Global Financing Facility for Women, Children, and Adolescents (GFF); Unitaid; the Foundation for Innovative New Diagnostics (FIND); and the Coalition for Epidemic Preparedness Innovations (CEPI). However, as noted in the introduction to the findings, in the interviews and consultations, informants spoke more about Gavi and the Global Fund and this emphasis is reflected in the findings.
The first finding concerns the evolving landscape relating to health financing, burden of disease and emerging challenges. The report notes a marked increase in the distribution of development assistance for health (DAH) through GHIs, driven by the creation of Gavi and the Global Fund, which accounted for 14% of DAH by 2019. It also states that “Four “mega-trends” of proliferation, verticalization, circumvention of government systems, and fragmentation are identified”. The first finding concludes that there are ‘emerging challenges …. which are unlikely to be addressed by the GHIs within their current mandates”.
The second finding relates to strengths and weaknesses of GHIs. The strengths noted are that GHIs, “by focusing on specific high-priority diseases”, have been “able to make a significant contribution to improving health outcomes in these areas, also mobilising additional funding to support that, and working with a range of actors to shape markets for global goods for these diseases, investing in improved and lower cost vaccines, pharmaceuticals, supplies and diagnostics. They offer funders tight controls on fiduciary risks and have adopted approaches which prioritise reaching target populations, which may be neglected by public authorities for a variety of reasons, including stigma.”
The weaknesses sound damning and the summary is reproduced here in full:
“However, these strengths are increasingly challenged, particularly when viewed from the country perspective, where funding by the larger GHIs has long been observed to distort national priorities and health systems, creating heavy costs in terms of preparation and implementation of grants, which do not use national systems, typically, or align with national plans, budgets, Public Financial Management (PFM) systems, human resource or information systems. Grant proposals developed by external consultants, away from the national context; siloed funding to elements and specific population groups within a system; support for unsustainable delivery strategies (in terms of cost); lack of focus on efficiency across the health system; lack of downward accountability of GHIs to countries, and failure to build national capacity to sustain gains in the long term (through system strengthening) are amongst the key concerns at national level. In addition, the results claimed by GHIs were always emergent from a wider set of investments, including by governments and other bilateral and multilateral funders.”
The third finding deals with the political economy; and this too is very critical of the GHIs:
“The GHIs solved many funders’ problems by creating structures which converted funding into credible results, while at the national level, clients were created who gained resources and therefore power from the funding. The wider global health system has been distorted by the relative volume of funding passing through GHIs, compared to other players with substantial roles, such as WHO. Incentives have been primarily focused on grant disbursement, more than achieving stronger, more effective and more sustainable health systems. Transparency of what is being spent in which health area and through what channels, as well as its longer-term impact on the health system, is still hard to achieve for some GHIs.”
The report sets out recommendations based on a vision in which:
- Implementing countries take increasing responsibility for essential, cost-effective interventions as and when they have the capacity and finance to do so;
- GHIs support countries in this effort, embedding sustainability, supporting affordable commodities, and setting clear trajectories towards transition; and
- Donors shift accountability for delivery more to countries, demonstrating a higher risk appetite and accepting broader Primary Health Care (PHC) and UHC results.
The report goes on to explain that the recommendations are grouped under six main themes:
- Making a stronger contribution to UHC, including emerging disease burdens.
- Strengthening or at least doing no harm to health systems.
- Reducing costs for countries and increasing efficiency and effectiveness of GHI investments.
- Supporting country ownership, capacity building and charting a clear path to ending dependence on GHIs.
- Enforcing more effective alignment between GHIs and with wider health actors.
- Limiting proliferation of GHIs; focusing on strengthening existing architecture.
The report then concludes with the key proposed changes which involve:
- Moving from disease-siloed to integrated delivery and care;
- Providing support to health systems as whole, rather than vertical components within health systems;
- Streamlining GHI systems (within and across GHIs) to make them more manageable and efficient at country level;
- Charting a clearer course towards ending dependence on GHIs, though building country capacity while also providing clarity on transition;
- Making alignment across GHIs into a core performance metric for them as well as for their funders; and
- Funders committing to strengthen existing architecture and reduce proliferation of GHIs.
This report comes across as somewhat biased; in fact it contains several inaccuracies. First, if funding is “creating heavy costs”, then why apply for the funding? Of course the preparation of funding applications and the activities involved in program implementation will incur costs; and measures can be taken within the grants to cover most – and sometimes all – of those costs, in one way or another.
Second, the Global Fund guidelines for preparing funding requests (FRs) place a heavy and repeated emphasis on alignment with and inclusion of references to national plans and priorities, health and other information systems. The GHI report authors seem to be unfamiliar with the FR preparation process because reviewers of draft FRs can testify that many of those drafts either fail to identify national and program priorities and/or include wish lists referred to as ‘priorities’ that are not referenced to national programs and priorities. With the best will in the world, external consultants are only able to do what the countries themselves wish to be done, or included in the FR. Also, health information systems are generally weak; and information on domestic health financing is invariably unavailable. The second finding is therefore factually incorrect and reflects the bias of interviewees in some countries who may not wish to admit their own shortcomings.
Third, there is a failure to recognise that FRs are prepared at the national level by or for Country Coordinating Mechanisms (CCMs). These have a wide range of national stakeholders, many of which have been involved in FR development through national dialogue and writing teams. The CCMs review and sign off the FRs. The criticisms levelled at the Global Fund (and other GHIs) and the so-called “key concerns” are therefore not the fault of the Global Fund but weaknesses at the national level. The FRs require careful preparation to ensure adequate prioritisation for the correct selection of priorities, consideration of financial and other resource requirements, and consistency with national health plans and priorities. That is why external consultants are engaged to assist in preparing many FRs when there is a shortage of suitably skilled and experienced persons.
The report states at the outset that “The study adopted a UHC lens and focused on countries’ experiences and needs from the GHIs.” That was not a realistic approach because, although all countries may have signed up to the concept of UHC, the reality is that many have no real intention of achieving it. This is evidenced by: (a) laws and/or attitudes that deter some populations (because of factors related to tribe, gender or sexual orientation) from accessing health services; and (b) the failure of most governments to increase their investment in health, so that sustainability is too far into the future to be considered attainable.
It is true that many GHI programs have tended to operate in silos; but that was not the intention. GHIs have to make most effective use of – and account for – the financial resources made available to them. Weaknesses in health information systems, lack of accountability, and a history of and risk of corrupt practices in the health sector have forced GHIs to be cautious because they have to ensure that adequate controls and reporting are in place. That is what has led to the silos. This cannot be corrected by the GHIs and the recommendations fail to recognise the risks inherent in some proposed changes. To achieve integration, national health authorities need to get their act together and show that they have properly managed accounting and management information systems in place, coupled with the necessary oversight, governance and accountability.
Moreover, countries themselves are guilty of running programs in silos. Vertical programming resulting in poor integration with and linkages between, for example, HIV and antenatal care or sexual and reproductive health – even HIV and TB with their close links – is much bemoaned by the Global Fund when they review the FRs.
Finally, the consistent call to build capacity is now hollow. GHIs alongside other multilateral and bilateral bodies have been providing training and technical assistance for decades. Too often, training is an excuse for a paid holiday with no investment yield. It is time for the initiative and responsibility to be taken at national level.