By Francisco Songane
Dr. Francisco F. Songane is the former Minister of Health of Mozambique; the Founding Director of the Partnership for Maternal, Newborn and Child Health hosted at WHO; and later chair of the Forum 2012 on Research for Health organized by the Council on Health Research for Development, where he served as Senior Health Advisor. He has extensive experience with the international community that has included serving as Executive Committee Member and Board Member of the Global Alliance for Vaccines and Immunization. Dr. Songane trained as a medical doctor and obstetrician/gynecologist at the Eduardo Mondlane University and Maputo Central Hospital in Maputo, Mozambique as well as at St. James University Hospital in Leeds, England. He has a Masters of Public Health degree from Boston University and a Masters of Science in Financial Economics from the University of London, England.
We invited Dr. Songane to speak at our symposium, ‘Disrupting Global Health Narratives: Alternative Perspectives on the World Bank’s Influence on Global Health,’ hosted by the Brocher Foundation near Geneva, Switzerland. Drawing on his vast experience working with global health institutions in many different capacities, Dr. Songane gave an important talk about the responsibilities and roles of global health actors and researchers in promoting health for all, and he has generously permitted us to post it on our blog for all to learn from him.
We are focusing on health, and I think that it is important to acknowledge the influence of the developments in health, particularly its contribution throughout the years in the shaping of the new development agenda which we are just beginning to implement, the Agenda 2030. For a long time health challenges have elicited collective effort within countries and internationally, from the perils of the bubonic plague and cholera pandemics that affected Europe in the 14th and 19th centuries respectively, the efforts to tackle major endemic diseases like malaria and river blindness, to the landmark achievement of smallpox eradication in 1980. Recently, the movement that emerged to fight HIV and AIDS, the action for the containment of SARS and other new viral diseases, and the raising of awareness about the plight of women in childbirth and children combined with a call for action, brought the economic and human rights elements to the debates, changing the perspective of viewing financing health as a mere expense and recognizing its place as investment in development.
History has taught us that fighting disease – and having the conditions in place to ensure wellbeing for everybody – is not the job of one sector alone, and in many instances international assistance is called for. It is in this context that many countries have resorted to bilateral cooperation with other countries and signed agreements with international financial and development institutions to supplement their resources and build technical capacity. The World Bank is one of the institutions that have been playing a key role in these cooperation processes, and rightfully the subject of this symposium.
The beginning of the 21st century, with emphasis on the first 5 years, saw the peak of the universal movement in the fight against HIV and AIDS, grounded on grassroot organizations and the coalescence of groups of scientists, complemented by a fast-growing number of policy decision-makers calling for change. At the same time, the rising awareness of the limited attention devoted to other important health problems captured the interest of new players, and this gave rise to new initiatives seen as a way of accommodating actors from outside the main stream linked to the public sector. It was in that period that GAVI and the Global Fund were created, along with other initiatives with a similar format to address specific issues related to health problems mostly felt in the least developed countries.
With this multiplicity of players engaged in activities of universal concern, albeit specific in their preferences and context, in a period of financial difficulties faced by international organizations with the mandate to manage health issues globally, dilution of responsibilities began to emerge, and in certain occasions decisions on funding for health activities of international concern were made outside the established platforms. Developments were occurring rapidly with the information shared only within limited circles, with wide gaps of communication with the countries, particularly the least developed; it was not rare for the countries to learn about it through a communiqué in the media or during meetings. It was then that the notion of global health was put forward, but without a structured arrangement to articulate its meaning and a clear governance. The power linked to capacity to fund became the leverage, thus bypassing the established institutions mandated for that purpose.
The countries most in need, already facing difficulties to provide health care for their people, found themselves having to deal with several and diverse initiatives and organizations, each one with its rules of engagement and conditions to provide support, outside the framework agreed upon with the existing international organizations that had the mandate to govern and administer global health. In some, Mozambique included, they had other domestic problems like reconstruction after severe conflicts, and also confronted with other political concerns of geopolitical nature which impacted on accessibility to funding and technical support for their development programs. The efforts for the reconstruction and reestablishment of services in the health sector involved numerous organizations, most of them of small scale operating in specific districts, and only addressing particular programs – everyone wanted to be acknowledged and claim success in its small geographic area of operation. So, on the one hand, new initiatives with their demands conditioning funding, and on the other, a considerable number of non-governmental organizations (NGOs) requiring agreements, and working separately, and this in a country with extremely limited capacity and without financial resources.
Global health researchers were focused on explaining the reason behind the initiatives, and looking for results in an attempt to document the relevance of the organization concerned, but left behind the challenges within countries related to the multiplicity of players of diverse nature, and with very limited human resources to match the high transaction costs with the management of the grants and coordination. There were some publications showing part of this kind of consequence, but their recommendations were overlooked, and quickly side-lined, and processes went on as usual.
The overall objective of technical and financial assistance is to assist the countries and work with them in their development efforts to improve their socioeconomic status and guarantee wellbeing of their citizens. To achieve this, developing national capacity is a critical determinant, with special emphasis on human resources. It would have been good and pertinent if global health researchers had also investigated the consequences of the transaction costs, assessing if the overall development of the country was being addressed. The conditions were set unilaterally without consultation with the countries, and were a basic requirement to get the funding, even if that meant abandoning the country strategy and neglecting the other programs not in the scope of the initiative or organization. It should be stressed, that even within a given program area, only some activities could be included, mainly related to procurement of commodities through a specific predefined stream. Alternatives the countries could turn to were not available either; there was a collusion of the major bilateral partners with the capacity to compensate, alleging that they have already contributed to fund A or B; meanwhile, international NGOs were being funded by the same bilateral partners, operating separately in some areas of the country, and this was used as an argument to justify “compensation” for not channeling the money bilaterally to the government in case it was not accepting the conditions imposed by initiative or organization A or B.
The Global Fund was set up to mobilize urgent funding for HIV programs which were well beyond the countries’ capacity to finance due to the then very high costs of the ARV treatment, with tuberculosis and malaria being included as a result of the immense pressure from the countries and activists, highlighting the strong association of tuberculosis with HIV, and the high burden of malaria, killing more people than HIV. Undoubtedly, HIV has prominence, and was the reference item in the setting of conditions, to the extent which demanding that nothing not related to HIV could be funded, and worse, the investments that were required in order to secure the implementation of some interventions should solely benefit HIV patients. A case in point is the prevention of mother to child transmission where only HIV positive pregnant women could be attended to in the refurbished and upgraded rooms, and all other women coming for regular antenatal care were excluded; likewise, laboratories were separated, those assigned to HIV could not process samples from the general requests in the health unit, just to mention two instances for illustration. Although under HIV and other vertical programs, these examples were the order of the day, they did exist in collaborations involving many other partners, including some UN Agencies, where for example would determine that an ambulance stationed in a general hospital to be used for the transfer of pregnant women referred to the central hospital could not take any other emergency.
How these attitudes were perceived by the people in the catchment areas served by those health units, or to what extent trust to the local authorities was compromised was not investigated. What were the implications in the implementation of the country strategy related to the delays, constant changes (which were imposed) or lack of consistency in program implementation?
In any country, the existence of a vision for development, and the respective strategies is a fundamental step to set the direction and guide activities. To take the case of Mozambique as an example, there was a health strategy, and there were workplans developed in close collaboration with key partners, but every time a new initiative came to light new plans were requested as a condition to receive funds, and had to match the requirements of the initiative. These decisions were made at the headquarters of the initiatives, and the donor countries that may have been invited during the preparatory process were represented by officials from the capitals with little synchronization with their colleagues based in the countries from the “South.” As a result, when new plans were demanded, the local offices of those bilateral partners who collaborated in the development of the country strategy and workplans were unable to argue in favor of the national plans, and were left with no choice other than complying with the position from the headquarters. This lack of coherence, strictly linked to inconsistency in strategy implementation and other distortions, is one of the reasons for a very slow progress in some of the least developed countries. An additional factor that makes matters worse is the political instability, or mere political games, where the change of government often brings with it new plans and the discontinuation of what had already been started.
This is an important area for research; international assistance has been going on for decades, so why the status quo? Has this assistance been truly to see the countries develop to their fullest potential, and rapidly minimize their dependence on funding and technical assistance from outside?
The reality on the ground does not seem to support this aspiration. The conditions imposed whenever the country asks for assistance, contribute to stoppages of the implementation of a vision or masterplan for development, and the government cannot be in full control of the rhythm of activity implementation. Further, in many instances workplans are completely changed, and parallel mechanisms are introduced in program implementation involving external actors; resources are deviated from the country institutions, with the consequent migration of the best cadres, thus undermining the process of capacity building.
The expected logical attitude of having the program or activity of a new initiative or organization integrated in the existing and approved workplan did not occur; on the contrary, what was demanded was the preparation of new plans restricted to some specific activities suiting the objectives of the initiative, and in an extremely tight time frame. There was a sequence of initiatives addressing important areas for the countries most in need to which countries had to apply to access funds, which resulted in a vicious cycle of plan design, then start implementation, then stop, then design new plan, then start implementation, then stop, and so on.
It should be pointed out that there were cases where strong leadership and coherence within governments did change the course, with the country not deviating from its strategy, and the activities promoted by new initiatives incorporated into existing plans. This could be a theme for case studies comparing these experiences with those of countries which had to keep changing their plans and comparing the results in terms of overall development, not only the number of people benefitting from a particular treatment.
Quick results, and the pressure to demonstrate success, rapidly has been the mantra of almost all the initiatives, even if they addressed an area for which it is not possible to see results in an extremely short period of time, as initiatives are usually required to show results within 6 months to a year. It is in this context that the initiatives’ reports had a common way of presentation – for example, with the number of people treated, number of lives saved – but not the way the country was progressing in delivering health for its people.
It is a good practice to report back to the funders to show how the money was utilized, but fairness should prevail, and efforts be made to be inclusive, factoring in the contributions of other partners, and provide the context in which the operations are undertaken. Money is critical, particularly for the procurement of expensive commodities, but without a working system in place, clear policies and a coordinated effort involving all the interested parties, success cannot be achieved. Certainly, the new initiative brought in an important element, often a critical one as in the case of the availability of funds, but in communicating the results, all the contributors should be acknowledged by practicing an inclusive discourse. Research on this particular subject could generate information to help in alleviating the pressure coming from the political bodies (parliaments) whose representatives demand results in short time frames. Perhaps to devise a research plan to study the development processes of country recipients of international assistance to analyze the implications of the way assistance is provided in the development trajectory, identifying the impairment factors and those that facilitate progress. The product could serve as the basis to construct a new narrative for the funders and their political backers highlighting the importance of the overall development for the sustainability of success in program implementation.
The World Bank, with its clout and wide mandate could be seen as the “backbone” of development assistance, adopting a comprehensive approach in its work with countries and contributing to the maintenance of the platforms for development. To fulfill this role properly, it may be pertinent to disengage from the initiatives it is participating in, and concentrate its activities at the country level in a holistic way as part of the implementation of the country strategy for development. If a similar role could be played by the regional development banks, it could enlarge the support base for the countries in their efforts to counter the negative effects linked to the conditions set by the different initiatives. The current situation faced by several countries is unsustainable, keeping them in a sort of a “trap” dependent on grants from initiatives, which are increasing their share in terms of funding international assistance for health, which together with NGOs represent 53% of the total development assistance for health.
At the same time, action would be needed from another angle to devise mechanisms to “insulate” the World Bank and other development banks from geopolitical issues, which in some cases influence their decisions with detriment to the countries. A process in this direction could also trigger the rethinking of the overall funding architecture in the light of the Sustainable Development Agenda, which clearly points to a comprehensive approach. What is the justification for keeping specific funds for specific diseases in this new era?
The current global health narratives are not affecting policy decision-makers only but researchers as well. Most of the research on global health is conducted by institutions in the North, with very limited contribution in the development of capacity of the local institutions in the South. Shortage of financial resources and incipient technical capacity are critical factors contributing to the perpetuation of the current state of affairs. Many world leading universities opened global health departments in the respective schools of public health and budgeted for it, and other institutions with interest in international matters are also studying this topic relying on researchers from the North.
On the other hand, at the country level, capacity development of research institutions has been relegated to a secondary plan. Lack of funds has hampered the efforts to revert the situation, and human resource policies on incentives have not benefitted equally for staff working in research as compared to their colleagues in program implementation. Money from development assistance could be an alternative, but the strict conditions are a limiting factor as the focus is on the implementation of programs.
There are instances where researchers from the North do involve colleagues from the South as co-researchers, but it stops short of taking this collaboration further to contribute to capacity development of the institutions concerned. It would be interesting to conduct a review of the collaborations set up to conduct global health research and assess their contribution in the development of the local partner institutions. I think it is also extremely important to also suggest that from now on, in every research undertaking involving work with and/or in countries receiving health development assistance, the actors should be required to make arrangements that include researchers from the countries concerned, complementing with assessing the feasibility of twining a local institution with an international one. For the cases where this cannot be done with the country, then a regional institution could be an alternative. More funds will be needed, but that is the way forward to break the cycle of dependence.
We need clarity in the governance of global health, and the role of the World Health Organization has to be redeemed.
The approach of earmarking funds went beyond the new initiatives, and has been embraced by some key bilateral donors, including in the funding of well-established international organizations. Gradually, these organizations saw a shift in their portfolios with a rise of earmarked money in their budgets, thus hampering their ability to fully fulfill their mandates. Under these circumstances, the UN agencies could not also honor their role in providing support to countries given the predominance of earmarked funds in their budgets. Further, philanthropies and the private sector are also coming on board in the funding of UN agencies through the mode of earmarked funds.
Their share in health development contribution is considerable, and in some cases matching that of voluntary contributions from the USA, and superseding key players like the European Commission or the UK on the same rubric. As a result, UN agencies end up with high proportions of their budgets (more than two thirds) funded by “tied” money, thus limiting their flexibility to fully deliver on what they are mandated to do. Funding mechanisms are becoming an instrument to control the agenda of UN agencies, circumventing the established governing bodies. The universality of the UN is being undermined, and now, in addition to the imbalance of power in favor of very few member states, there is a looming private sector as well as philanthropy organizations seeking a place in the governance or decision-making processes.
We are at a critical juncture where the information gap between the donor networks and the countries is getting bigger. There have been calls to change the situation, and analytical work has been published focusing on the legality and institutional arrangements vis-à-vis the mandates of the international organizations, in the context of the debate around the governance of global health. It may be worth bringing up an argument from the countries’ perspective, highlighting the reversal of the gains that had been made and the lack of clarity in the governance of global health issues linked to the implications in the relevance and trust of the international organizations, with emphasis on the UN agencies.
These are my inputs as a contribution to disrupt the global health narratives currently skewed to the donors’ side.
This is a window of opportunity; we are at the beginning of the implementation of the new global development agenda, the Agenda 2030, which is comprehensive and addresses all socio-economic areas; indeed, all the pillars for development. All the interested parties in international cooperation signed up to the sustainable development agenda, so it is time to adjust, break the silos of “we” and “them” or “we do it for them” to be together, integrate efforts, and provide substance to the spirit of the Sustainable Development Agenda.