Governance for the future of global health, by Peter Piot

The Lancet –  This year will see major changes in leadership at WHO and at the Global Fund to Fight AIDS, Tuberculosis and Malaria, and probably in some other health-related multilateral organisations as well. History has shown that an able leader at the helm can make a difference. However, governance, organisational culture and performance, and funding equally define a leader’s effectiveness. In the case of multilateral institutions, these are complex matters given the conflicting interests of their multiple stakeholders. That global health governance matters was dramatically illustrated during the 2013–16 epidemic of Ebola virus disease in west Africa. At a time when globalisation is questioned by millions, multilateral institutions are more important than ever when it comes to health: in an increasingly interdependent—but also divided and unequal—world, pooling of resources increases efficiency of global health actions, and epidemics require supra-national action.

Around the millennium, a number of international public–private partnerships were launched to accelerate infectious disease and nutrition programmes. This approach was inspired by a perceived failure of the UN system to deliver action on the ground, and the hope to expand funding beyond traditional public donors. These efforts were also designed to overcome market failures in research and development, and to provide antiretroviral therapy in Africa. The Bill & Melinda Gates Foundation has a major role in the establishment and funding of this new generation of global institutions. Failure of WHO and the World Bank to engage with the public, civil society, and businesses entities was another reason. Gavi, the Vaccine Alliance and the Global Fund were set up to deliver greater efficiency, effectiveness, and accountability, and their support to low-income and middle-income countries would be demand driven and performance based.

In Governing Global Health: Who Runs the World and Why?, Chelsea Clinton and Devi Sridhar examine the governance, financing, and accountability of four major but quite different multilateral institutions: WHO, the World Bank, Gavi, and the Global Fund. In their own words, the book is about “why institutions behave the way they do, what decisions are made by whom, and how influence is exercised”. They provide a cogent, thorough analysis of these issues, although a limitation of the book is that it does not examine the effectiveness of the institutions.

The authors use “principal agent” theory as a framework that assumes that governments are the principals directing international organisations. International institutions usually act according to the priorities of at least the most powerful member states, but at times they can act autonomously and even against the interests of some states. This basic tension between often mutually exclusive interests of member states and the vision and actions of global health institutions lies at the heart of the governance and policy challenges of any multilateral system. There is sometimes a naivety among some global health non-governmental organisations and academics about the political and operational power that multilateral organisations can actually exercise. However, when I was head of UNAIDS I certainly found there was space to push the edges of policies that were not popular with many member states, such as gay rights and harm reduction among drug users, and even access to antiretroviral therapy when nearly all high-income countries were opposed to use of development resources for such treatment.

Clinton and Sridhar discuss the governance of the four institutions in detail, since it is the basis for their modus operandi and action. The authors point to a “democratic deficit” because of the absence of meaningful representation of civil society and private economic forces in these institutions. And yet, as they rightly highlight, non-state actors are essential in global health action—from organisations such as Médecins Sans Frontières during the Ebola epidemic to people living with HIV for the AIDS response, and to companies which employ millions of people, produce essential goods for health, or promote harmful products. WHO probably has the longest way to go to overcome this democratic deficit, because it still has a predominantly state-centred approach, and has the greatest difficulty interacting with both civil society and business. The World Bank has been opening up through its Civil Society Policy Forum before the Annual and Spring Meetings, although no such transparency exists for the World Bank’s interactions with the private sector on which similar standards of transparency are not met.

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How exactly to ensure representative involvement of non-state actors from across the world in multilateral decision making remains a question without a clear answer, yet it will be crucial for further progress in global health in the time of social media. Therefore, experimenting with various models is the way forward. In any case, making progress on this issue will also require greater independent accountability and transparency of conflicts of interest of all those engaged in governance and management, not only for the private sector, but also for those donating funds and benefiting from funds. For example, some perceive potential conflicts of interest among Gavi board members, including vaccine producers, whereas others see their membership on the board as a source of strength.

“Follow the money” is always a sound approach to understanding any organisation, and Clinton and Sridhar devote much attention to institutional funding. The reality for these four very different institutions is that they are basically funded by the same governments and, with the exception of the World Bank, also receive substantial funding from the Bill & Melinda Gates Foundation. Despite the original intent to attract private funding to the new organisations, large funding gaps remain—although Gavi has succeeded in attracting a larger share of non-traditional donor funding, mostly from the Bill & Melinda Gates Foundation but also through the Advance Market Commitment. Clinton and Sridhar document how governments and other funders increasingly use their contributions to shape the behaviour of multilateral institutions.

The failure of member states to agree on an increase of WHO’s assessed contributions (compulsory contributions of each member state) or even pay their contributions, has resulted in an increasing reliance on voluntary contributions, often massively earmarked for specific activities. This has resulted in increased control by the main donors, and at the same time difficulty for WHO to be a coherent organisation responding to the broader needs of all its constituents. Voluntary contributions are not necessarily wrong—most UN programmes and agencies are largely financed that way. If such contributions support institutional objectives agreed by the organisation’s governance and are minimally earmarked, they provide an incentive for accountability and performance. However, global normative functions, such as recommendations on health policies or the use of a particular treatment or vaccine, should be supported by the pooled institutional funding to dilute even the perception of playing to national and private interests.

The sections of the book on accountability, inclusiveness, and transparency are equally well documented. Again, WHO is the institution that requires the most urgent reforms, many at no or low cost. For example, as Clinton and Sridhar note, it is hard to understand that this public institution, mostly funded by tax payers, has no information policy, let alone a freedom of information policy. Ironically, WHO asks for full transparency from others, such as the pharmaceutical industry, investigators, and governments concerning trials.

Governing Global Health concludes with a list of reforms needed in each of the four institutions to remain relevant and contribute to global health in the decades to come as new health challenges emerge and the international political context and power relations may change drastically. The world clearly needs multiple types of global institutions. Some, such as WHO, are universal in nature, provide a platform for policy and political debates on health, and are a strong voice for promoting health grounded in science and human rights, even though they are by nature less focused. At the same time, the Global Fund and Gavi have been essential to achieve disease-specific agendas. So it is not one or the other. However, long-term sustainability of global health efforts, as well as the expansion into universal health coverage, health system strengthening, tackling the increasing burden of non-communicable diseases, pandemic preparedness, and climate change, will require a broader support base—and perhaps a next generation of multilateral institutions if the existing ones do not reinvent themselves. This book was written before the election of US President Donald Trump and the relentless tabloid campaign against official development assistance (ODA) in the UK. Their impact on the future of ODA funding for global health remains uncertain.

Clinton and Sridhar’s writing is precise and persuasive, and they offer a plethora of facts and data that are sometimes hard to find. This timely book is a must read for all stakeholders in global health—and certainly for the current and future candidates for leadership positions in global health—but also for students, governors, and practitioners of multilateral organisations. Perhaps they can enact some of the important messages in this insightful book.

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I am Director of the London School of Hygiene & Tropical Medicine. Governing Global Health: Who Runs the World and Why? will be published on Feb 9, 2017, by Oxford University Press USA.

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