Governance Challenges in Global Health PROFESSOR DR. ILONA KICKBUSCH GLOBAL HEALTH PROGRAMME THE GRADUATE INSTITUTE GENEVA BAD GASTEIN 3.10.2012 IGO 2 IGO 3 N1 CSO2 IGO 1 N2 CSO1 TNC1 TNC2 TNC3 A1 A2 C1 C2 A C A3 C3 B1 B2 B B3 HEIN
Global Health: what are the challenges? 2 Political determinants prioritizing health ensuring public goods the role of the state and institutions Inequity social determinants social protection on a global scale Environmental determinants climate change health co- benefits Globalisation of lifestyles commodification - non communicable disease commercial determinants Ressources and political will to Build universal access to health systems: infrastructure people products - financing Promoting health, fighting disease through innovation, science, research, technology
Global Health Governance Challenges 3 Complexity: multi polar multi stakeholder world Interdependence managing globalization Insufficient global committment to health in view of other interests political and commercial determinants The role of the state, sovereignty where does democratic accountbility lie Too many actors no coordination lack of accountability Lack of clear mandates mission creep Lack of influence in sectors and agencies that matter for the determinants of health Wrong type of goals Charity model - unreliable financing mechanisms
New dynamics through context New power centers new political actors New sources of wealth privatization of global action -Role of private sector, philanthropies Half of global economic growth occurs in the developing world More poor people live in emerging economies new redistribution challenges Bottom Billion, fragile states Civil society, NGOs..people based social networks - social media 4
How do we govern? 5 20th century Creation of universal membership organisations League of Nations United Nations INTERNATIONAL 21st century Creation of multistakeholder hybrid organisations and initiatives New multilateralism GLOBAL - transnational
Short history of global health governance 1 Period Political/ Historical features Health sector Global health governance 19th century Industrial revolution, economic development, Colonialism Epidemics (cholera, plague, and yellow fever) Hygiene 1838 Superior Health Council of Constantinople 1840 Sanitary Council of Tanger 1843 Egyptian Quarantine Board 1851: First (of 14) International Sanitary Conference in Paris (failed for 40 years to agree on quarantine measures for cholera) 1867 Sanitary Council of Tehran 1859 /63 Battle of Solferino Henri Dunant describes suffering of war victims in a Memory of Solferino International Committee of the Red Cross (ICRC) 1890-1910 First International Conference of American States Flexner report on medical education in US & Canada ( a century of medical exceptionalism) Discovery of yellow fever transmission and 1 st eradication campaign in Havana Pan-American Sanitary Bureau PAHO Rockefeller Foundation International Public Hygiene Office in Paris (OIHP 1907) 1919 Hygiene organization of the League of Nations
Short history of global health governance 2 Period Political/ Historical features 1945/48 End WWII/ United Nations 1991-2000 End of cold war, short unilateral period, antimultilateralism, Helms-Biden Act Health sector AIDS Global health governance World Health Organization WHO Criticism of WHO Gates Foundation (1994) GFATM (2000) GAVI Alliance UN Millennium Development Goals 2003/05 SARS H5N1 2006/09 G20 Summits H1N1 Global financial crisis Pandemic NCD s 2011 2012 FCTC IHR (2005) Oslo Ministerial Declaration on Global Health and Foreign Policy First UN GA resolution on Global Health and Foreign Policy Calls to Strengthen WHO UN NCD Summit WHO Reform
The New Multilateralism and Global Health Governance Landscape 1892 Accountable to citizens WHO UNFPA World Bank Accountable to Member States GFATM GAVI PMNCH RBM SUN etc. 2000 8 gongo? Accountable to who? Donors? Constituency? Board? Markets? Me? pingo ingo bingo ringo HPA gongo are government organized NGOs pingo are public interest NGOs ingo are large internatonal NGOs bingo are business interst NGOs ringo are religious interest NGOs HPA Health Professional Associations GFATM is Global Fund ATM GAVI is GAVI Alliance (Vaccines & Immunisation) 1945 UNAIDS Unicef (IPU) UN Foundation Consumer groups Foundations Academic groups Movements etc. 1948 PMNCH is Partnership for Maternal, Newborn & Child Health RBM is Roll Back Malaria SUN is scaling up nutrition movement Germann 2012
Partner creation and effectiveness 9 Low Beer 2012
Some Challenges & Opportunities of new players in GH 10 Challenges Opportunities Legitimacy of actors Democratization of health Accountability to whom Convergence for impact & scale Conflict of Interest Movement creation Complexity through numbers Increased resource allocation Transactional costs Addressing Social Determinants
GOVERNANCE TODAY Governance today is characterized by a plurality of actors (states, corporations, the World Trade Organization, institutions of civil society, criminal and terrorist gangs) forming more or less interconnected governance networks; a plurality of mechanisms (force, persuasion, economic pressure, norm creation and manipulation); and rapid adaptive change. Conventional models of how governance works are hard put to encompass these many elements we cling to the old models, working ever harder to fit the phenomena we observe into the forms of the past. Burris et al 2005 11
Redefining development 12 "It is time to put aside the 20th-century conception of the development project as primarily about charity or aid from rich to poor nations. The global economic crisis illustrates that we live in what is now an interdependent global system, in which the prosperity and security of people in the rich world can no longer be guaranteed within rich countries own sovereign borders. It is not just the economic crisis that clarifies this interdependence, including that of the world s rich minority on the capability and welfare of the world s poor majority: the problem of climate change, for instance, cannot be managed by the rich world alone, nor, for that matter, can the risk of global pandemics or the challenge to social order of cross-border corruption, drug trafficking, and illegitimate tax flight." Development should be defined in terms of a global social contract analogous at the global level to the domestic social contracts of the mature Western democracies. (Nancy Birdsall 2009)
Busan 4th High Level Forum 2011 We, Heads of State, Ministers and representatives of developing and developed countries, heads of multilateral and bilateral institutions, representatives of different types of public, civil society, private, parliamentary, local and regional organisations meeting here in Busan, Republic of Korea, recognise that we are united by a new partnership that is broader and more inclusive than ever before, founded on shared principles, common goals and differential commitments for effective international development. Busan 2011 13
Key Differences between Paris & Busan Moving from inputs (aid) to results (development) 14 Shift from focus on Northern Aid for aid dependent low income countries to include South South cooperation and increasing role of BRICS++
BRICS HEALTH MINISTERS MEETINGS 15.. To promote BRICS as a forum for coordination, cooperation and consultation on relevant matters related to global public health.institutionalize on a permanent basis First theme; access to medicines Establish technical working group
Innovation in global health 16 Social movement for development and health: based on the dividends of development which still come from social investments to educate a new generation and remove the diseases of poverty. It brought together diverse partners, which went beyond traditional health institutions Creation of global health partnerships to address global risks: this movement created innovative health partnerships. They reflected a new partnership between the public, private sector, civil society, private, foundations, and multilaterals to provide global not fragmented, responses to global risks New constituency model of governance: the new actors have evolved beyond just innovative partners. They have become constituencies in global health, and claimed a space in health diplomacy and decision making. This is changing governance mechanisms, globally and in countries (Low Beer 2012) 15 years ago, difficult to predict Bill Gates programming global health rather than software, NGOs governing a US$20 billion global health fund, WHO convening a wide range of partnerships, financial markets launching bonds to support vaccines, Bush announcing PEPFAR, Bono selling RED products alongside his music
Multi stakeholder Governance 17
Constituency model of governance 18 Civil Society Private Foundations Private Sector Not the number but the diversity of partners, domains, interests Internalise roles not just as partners but as new constituencies in structure, decision making and diplomacy People affected by health issues Government Multi laterals Bilaterals Working through Partners for health outcomes: Health outcomes are determined in communities, bars, villages, bedrooms, workplaces, and we need to mobilise resources in these contexts to tackle health risks. Low Beer 2012
Multilevel governance FCTC 19 Mamudu 2009
Climate change and health: Impacts and pathways 20
GLOBAL HEALTH 21 Complex adaptive system All actors should be: A1 A A3 A2 IGO 2 IGO 3 CSO 1 IGO 1 N2 TNC 1 TNC 2 TNC 3 B 1 B 2 B B 3 N1 CSO 2 C1 C C3 C2 Bound by values Bound by rules of behaviour Transparency - accountability Evaluated independently ( rating agency ) Convention constitution 1st step: Committee C WHA
Who needs to come together? 22 Khanna 2011
Role of WHO 23 The key governance challenge is setting the rules for the new interfaces ENSURE GLOBAL PUBLIC GOODS Representation, finance, accountability, transparency UN system: increased value of universality; convening power; regulatory power; infrastructure; intelligence ROLE OF WHO to act as the directing and coordinating authority on international health work
WHO reform agenda 24 Priority setting WHO has to focus on it s core functions Priority setting needs criteria to set priorities and tools/ procedures to stick to and renew the priorities Stakeholder involvement Directing and coordinating authority needs to be interpreted differently as platform of coordination A balance between strong and attractive involvement of all key stakeholders and the respect for the sovereignty of nation states has to be found Financing No organization can be well run with <20% of stable financing regular budget of WHO will have to increase and other sources found Managerial Governance
WHO s use of policy instruments Traditionally WHO only considered itself as a technical agency, using at most soft law instruments Some soft law instruments became historical landmarks (e.g. Alma Ata declaration on Primary Health Care, Ottawa charter on health promotion) WHO discovered international law through FCTC, followed by IHR? In recent years soft law development became more often negotiated though intergovernmental processes Growing importance of health relevant negotiations in other fora Are WHO and MOH s ready for this more political / diplomatic landscape? Or will we see a hollowing out of representative institutions?
Upcoming challenges for WHO in global health diplomacy Agenda / Challenge Link to health diplomacy Increased societal and financial relevance of global health Universal coverage NCD epidemic Social determinants of health, Health in all Policy, Whole of Government approach Post-MDG targets Access to medicines WHO Reform Health as largest economic sector New health treaties More 26 controversies and more foreign policy in health Interaction with social and financial sector. Need for intersectoral action and diplomacy, collaboration and managment of conflicts of interest with private sector Need for true dialogue with many sectors mainstreaming health Negotiating health, overcoming Developing/ industrialized countries split, sustainable development Trade conflicts in health diplomacy Fulfill the constitutional mandate to act as directing and coordinating authority Many other actors will become interested and negotiating more controversial Trend to more formal negotiations
Establish new financing streams 27 Development Global Public Goods Shift from aid efficiency to development impact Triangular action Partnerships to address the poorest (collateral goods) Legally binding transparency requirements for extraction and oil companies EITI Solidarity Tobacco Contribution Airline tax - carbon tax Financial transaction tax
28
Financial weight of WHO Relatif relevance of WHO 5000 4500 budget in Mio US$ 4000 3500 3000 2500 2000 1500 1000 500 W HO regular bud get W HO total bud get W orld Bank D AH GAVI GFATM BMGF he alth disbu rsem ents U S NGOs oversea s health e xp enditures U S U K 0 Data source: IHME, DAH database 1 990 2000 2007 year - WHO's overall budget compared to overall international financing on development assistance in health has decreased from 23% in 1990 to 11.4% in 2007 29 - WHO s regular budget has not increased at all
Good global health begins at home 30 Coherence and cooperation, strategic goals, intergovernmental structures (ie Switzerland, UK) involvement of stakeholders at the national level ie preparing for WHA Thailand Link national and global health policy (Brasil, Mexico, Kenya) Selections and preparation for international and global functions composition Delegations to WHA Health attachés Follow through AFTER
Responsibility European Union The Council welcomes the Commission Communication on the EU Role in Global Health which highlights the need to take action to improve health, reduce inequalities and increase protection against global health threats. Health is central in people's lives, including as a human right, and a key element for equitable and sustainable growth and development, including poverty reduction. 31 Council of the European Union Adopts Conclusions on the EU Role in Global Health 10 May 2010
Mechanisms for interface 32 Governance for Global Health Multi level governance at national and regional level Global Health Governance Governance of the global health system Global Governance for Health: Health and other governnce sectors
Diplomacy today Health policy today 33 Today s diplomat has a dual responsibility: to promote his or her country s interest and to advance the interests of the global community Muldoon et al 2005 Today s minister of health has a dual responsibility: to promote his or her country s health and to advance the health interests of the global community.