Emergence & Evolution of GHIs

Carlos Bruen & Ruairí BrughaRoyal College of Surgeons in Ireland

Aims & Methods of Study

Analysis of the emergence & evolution of GHIs•GHIs: GAVI Alliance, Global Fund, PEPFAR, World Bank MAP•Focus at the global level and global-country interface•Focus on issues of partnership, governance, influence of individuals, organizations and networks in the evolving design and policy priorities of GHIs

Methods•Documentary Reviews•Stakeholder mapping & in-depth telephone interviews of purposively selected individuals (n=36) (2009-11)•Recorded, transcribed, anonymised, thematic analysis

Interviewee Characteristics•Constituency Affiliation at time of interview•Constituency Crossing•Multiple Roles

Actor-Centered Analysis

Object of Research: GHIs

-New institutions within the field of Global Health Governance that drive a global agenda at the country level

-Comprised of individuals and organizations across multiple constituencies, aim of which is to address collective action problems

Cf: Adam & Krisei (2007); Fligstein & McAdam (2011); Hein et al (2009);Jackson (2010); Walt & Gilson (1994)

Health Policy Analysis

•Global Health Governance

•Comparative Institutional Analysis

•Network Analysis

•Strategic Action Theory

General Overview - Actors in GHI Emergence

• Modus operandi rooted in the influence of different stakeholders at the time of GHI formation

PEPFAR Global Fund GAVI Alliance

Policy Community Type

Closed - Small policy communityOpen - Multiple policy communities within broad issue network

Semi-open - influential small, closed policy community in broader issue network

Key Actors in GHI design

•Core: US Federal agencies •US Congress negotiations & NGO/private sector lobbying

•Core: Transitional Working Group •G8(financial), African govs (symbolic)•Consultations with countries, civil soc , private sector (+ traditional actors)

•Core: PATH, vaccine reps from multilateral institutions, private sector and Gates Foundation•Reps from European donor orgs•Consultation through personal networks

Cited Justifications

•Global Fund slow in releasing finances, PEPFAR as emergency response and ‘catalyst’.•Soft power focus on Africa •Need to improve coordination of US agencies

•Need for a ‘war chest’ •Address failures of existing strategies, incl. UN system•Involve public and private stakeholders •‘Lean and Mean’, ‘quick wins’

•Counteract falling priority of vaccines & UN systems’ weaknesses• Involve public + private stakeholders (eg WHO) in an ‘alliance’ to get buy-in•‘Lean and Mean’

Examples of policy outcomes

•1/3 spending for abstinence only programs, anti-prostitution pledge & no funding to needle exchange programs•System preference for US-NGOs•Top-down influence on national reforms•Greater NGO role in service delivery

•No country presence•Worked with (separate to) UN agencies•Focus on 3 diseases, but early focus on HIV/AIDS treatment scale-up•Use performance-based funding•Increased NGO role for service delivery and governance

•No country presence but use EPI (immunisation) infrastructure•Focus on new and increased access to existing vaccines•Use performance-based funding•Increased NGO role for service delivery

Case Study 1: Global Fund & Civil Society: From Transnational Advocacy to Actors in Governance

• Transnational civil society treatment advocacy network formed throughout 1990s

• Influence over negotiations• Directly though high-level cross-constituency ties to political and bureaucratic elites

• Indirectly though wider network tactics (information, symbolic, leverage and accountability tactics)

• Reflected in resulting Global Fund architecture and priorities

• Influence over evolution of structure and policies

• Including i) communities voting rights; ii) dual-track financing; iii) pressure to approve procurement of generic medicines; iv) widening of original GF framework despite high-level opposition; v) increasing influence of Southern NGOs

• Enduring Challenges• Perceptions of undemocratic processes and limited stakeholder representation by a

small number of NGOs in global and country Fund governance structures

• ‘Civil society’ complexity, masking divisions and rivalries between NGOs at the global and country levels and the divisions of lab our that have emerged

• Managing multiple ‘upwards’ +‘downwards’ lines of accountability + avoiding donor co-option

Case Study 2: GAVI Alliance as a Strategic Action Field• What precipitates major institutional change?

• Context of GAVI Emergence: Collapse of Child Vaccine Initiative, breakdown in actor relations & low priority for vaccines

• Phoenix rising: Formation of a small immunization community that vied for strategic advantage in GAVI design phase through use of strategies to increase financial and social capital and get wider buy-in

• Incumbents Challenge: Processes that led to an increased attention to HSS as GAVI evolved included:

• Emergence of evidence on health systems’ weaknesses, undermining vertical approaches; • Changes in GAVI governance structures, actor composition and relative power; and increases in

donor contributions and HSS financing through IFFIm; • Opening of ‘policy windows’ and political opportunities to advance broader health systems’

support

• Settlement: While partially successful, the challenge was undermined by:

• Weak evidence of the benefits of investments in health systems strengthening, reinforcing the Gates Foundation’s support at Board level for vertical investments;

• Fragmented health systems coalitions;

• The global financial crisis and reduced donor financing for HSS.

GHIs & HSS: An Uncomfortable Co-Existence• Global Fund

• Strong opposition to deviating funds from three diseases and hit by a fiduciary, financial and management crisis - aid effectiveness (a pre-condition of HSS) being overtaken by more immediate restructuring and financing concerns (McCoy et al, 2012)

• Assessment of systems effect remains built in to GF funding framework

• GAVI• While HSS remains an important strategy, some Board members opposed to

departing from GAVI goals. Negotiated compromise resulted in a selective HSS strategic goal being adopted, Strategic Goal 2 (2011-15)

• Consensus has been lacking on HSS, while opposition against financing a perceived unmeasurable HSS ‘black hole’ remains strong

• Influential political coalitions or resource mobilization for HSS has not been forthcoming, while HSS policy communities remain fragmented.

• HSS perceived to have a weak evidence base and measurable indicators of impact are lacking or highly contested

• GHIs and donors have shifted from speed and volume to effectiveness of disbursements – may lend support for shorter-term performance indicators

Conclusion: GHIs, HSS & UHC

• Strong health systems fundamental to achieving UHC. However, HSS rhetoric not matched by financial commitments (IHME 2011; Hafner & Shiffman, 2012)

• UHC: How might it be realised in this context?

References

• Adam, Silke, and Hanspeter Kriesi. "The Network Approach." In Theories of the Policy Process, edited by Paul A. Sabatier, 129-54. Boulder, CO: Westview Press, 2007

• Brugha, Ruairi. "Global Health Initiatives and Public Health Policy." In International Encyclopedia of Public Health, edited by Kris and Heggenhougen and Stella Quah, 72-81. San Diego: Academic Press, 2008.

• Fligstein, Neil, and Doug McAdam. "Toward a General Theory of Strategic Action Fields*." Sociological Theory 29, no. 1 (2011): 1-26.

• Hafner, Tamara, and Jeremy Shiffman. "The Emergence of Global Attention to Health Systems Strengthening." Health Policy and Planning (2012)

• Hein, Wolfgang, Scott Burris, and Clifford Shearing. "Conceptual Models for Global Health Governance." In Making Sense of Global Health Governance: A Policy Perspective, edited by Kent Buse, Wolfgang Hein and Nick Drager, 72-98. Basingstoke: Palgrave Macmillan, 2009.

• IHME. "Financing Global Health 2011: Continued Growth as Mdg Dealine Approaches ". Seattle, WA: Institute of Helath Metrics & Evaluation, 2011

• Jackson, Gregory. "Actors & Institutions." In The Oxford Handbook of Comparative Institutional Analysis, edited by Glenn Morgan, John Campbell, Colin Crouch, Ove Kai Pedersen and Richard Whitley, 63-86. Oxford: Oxford University Press, 2010

• McCoy, David, Carlos Bruen, Peter Hill, and Dominique Kerouedan. "The Global Fund: What Next for Aid Effectivness and Health Systems Strengthening?". Nairobi, Kenya: Aidspan, 2012

• Walt, Gill, and Lucy Gilson. "Reforming the Health Sector in Developing Countries: The Central Role of Policy Analysis." Health Policy & Planning 9 (1994): 353-70.