Comment
Offline: The panjandrums of global health
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She was angry and upset. She directs the policy, planning, and financing division of an African Ministry of Health. She never represents her country on official panels at the United Nations. She doesn’t write papers for medical journals. And she isn’t consulted by the giant panjandrums of global health. Nobody asks her for her views. Nobody is interested in her experience. But what she knows, and what others should know too, is important. The indifference of all of us—The Lancet too— to those who actually “do” global health in countries raises questions about just what our efforts really achieve. How can global health succeed if it doesn’t listen to those on the front lines of policy making in countries we profess to care about? Her task in her ministry was to work with “partners” to strengthen her country’s health system. (It is worth emphasising that the word “donor” is now unacceptable in global health, although the replacement word “partner” has become a dishonest way to cover up the enormous power imbalance between what are still, like it or not, “donors” and “recipients”.) Specifically, she has to persuade those who lead Global Health Initiatives to pool their windows of spending on health systems. Her guide is the 2005 Paris Declaration on Aid Effectiveness: country ownership, alignment, and harmonisation. Countries should be able to set their own strategies for poverty reduction; donors must align behind these objectives and use local systems to do so; and donors should coordinate and simplify their procedures to avoid duplication. The 2012 Busan Principles for Effective Development Cooperation were supposed to provide a new and better vision for the relationship between development partners. They should have helped strengthen the ability of this African policy director to negotiate with reluctant “partners”. Instead, Busan said that “development depends on the participation of all actors, and recognises the diversity and complementarity of their functions”. Busan lacked the clarity of Paris. It fudged the responsibility of donors. It was a step backwards, not forwards, for development cooperation. *
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Our African policy director’s “partners” were the World Bank, the Global Fund, and the GAVI Alliance. She brought them together and asked if they would pool their health systems spending budgets to support her government’s 112
health system strengthening programme. She also asked them to agree a single reporting mechanism to ease the administrative burden on her country. Immediately, the World Bank refused to take part. They wanted total control of their money and they wanted a separate means to monitor that money, irrespective of the difficulties it caused the country. The Global Fund and GAVI were more reasonable. They agreed to try to negotiate a common framework for disbursing their investments. And they committed to devising a common resource tracking mechanism. The negotiations went on for a year, but eventually broke down. The ministry now has three separate channels for health system support and three separate monitoring mechanisms it has to service for its three “partners”. “IHP+ is not working”, she told me. The International Health Partnership (IHP+) is nothing more than “multiple fracture and fragmentation”. The transaction costs are huge. And her ministry is “paralysed”. * At this year’s World Health Assembly, the World Bank’s President, Jim Kim, asked his audience at a technical briefing on the IHP+ to tell him bad things about the Bank. His openness was disarming and raised (nervous) laughter around the room. Nobody spoke. But if President Kim had visited a small room in an African Ministry of Health instead of the Palais des Nations in Geneva, if he had spoken with someone who never speaks to a President or a Director-General or an Executive Director of a global agency, and if he had heard one woman’s bitter passion instead of obsequious trivialities at the World Health Assembly, he would have seen a different world from the one his advisers and the international bureaucracy would have him see. It is the same for Margaret Chan, Anthony Lake, and even Ban Ki-moon. Who really tells these people the truth? Do they sit down and really listen to those who know what is happening in countries? And if they do, does anything change as a result of their listening? 15 minutes with the woman from this African country would tell our global health panjandrums a great deal about the world they preside over. And the problems they choose to ignore. Richard Horton
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www.thelancet.com Vol 382 July 13, 2013