The call for institutional reform is increasingly replacing the search for bold ideas in addressing global health challenges. What the UN health agencies need is not tinkering, it is vision and courage among their leaders.
Seen from inside the UN system, global health has become a jungle. It is cluttered with new health institutions, a thicket of new partnerships and a confusing array of NGOs, foundations and engaged corporations. This group of new and assertive actors seems to be confusing global priorities, draining funding away from the UN and usurping its authority.
The World Health Organization (WHO) document on ‘engagement with non-state actors’, published last May, gives the sense that WHO wishes they would all go away. UNAIDS’ Executive Director, Michel Sidibe, has long complained about the ‘complexity of the global health architecture’.
At least Sidibe has some ideas about how the UN should respond. He argues for merging UN agencies with the GAVI Alliance, the Global Fund to Fight AIDS, Tuberculosis and Malaria and perhaps one or two other outsiders to create three super-agencies under a UN umbrella. There would be one for funding, one for setting policy and one for advocacy. This has led to concerns from other health-related UN agencies, which are suspicious that something ‘is cooking’ but cannot quite figure out what.
From outside the UN, however, this hand-wringing seems strangely overwrought. If donors are to be believed, they have never got more health for their money than in the past decade from these new non-UN institutions. These have been a godsend for politicians who have seen development aid spending coming under increasing pressure. Institutions such as the Global Fund have saved millions of lives and provided the politicians with a ready-made formula for showing how money can be spent effectively on things that there is broad agreement on, such as immunizing children and saving women and children from dying of AIDS and malaria. Moreover, these institutions are acutely responsive to donor pressure, and – compared to the UN system – nimble in their ability to change.
Foundations provide a steady stream of new ideas and analysis, as well as funding for things governments do not find money for. The many partnerships do an uneven, but generally decent job in herding all the cats that make up the important players in global health today. The NGOs are not doing badly either; at times pretty much dictating policy to UNAIDS and others.
For recipient countries, though, the new funding institutions, and the foundations and NGOs following in their slipstream, are hard to understand and to please. Dealing with them is labour-intensive and they can be patronizing on occasion. Nonetheless, the Global Fund is easier to deal with than a combination of 15 bilateral donors, and these new players bring large amounts of money compared to the UN.
The irony is that, while the UN agencies discuss dramatic structural reform, they also fear the world outside may already have come to the conclusion that the UN is no longer important enough to be worth reforming. No UN ambassador in their right mind would want the pain of starting a process to re-write the charters and merge the different agencies that streamlining the UN would involve. So donors are simply slowly turning off the funding tap to the UN agencies, citing lack of efficiency and the slow pace of change.
That is a shame. Little of the progress in global health over the past decade would have been possible without the UN agencies. UNICEF and WHO may have lost their way on vaccines during the 1990s and needed GAVI to revitalize that sector, but without them, GAVI simply would not work. To a lesser extent, that is also true for the Global Fund.
In areas such as accident and violence prevention, emergency health, outbreak monitoring and control, non-communicable diseases and global health policies, there are simply no good alternatives to the UN agencies, creaky and dysfunctional as they are.
What is missing among the current UN agency heads, Sidibe apart, are new ideas, vision and leadership.
UNICEF is still looking backwards, focusing on the 20th century problems of child survival (a safe fundraising strategy) while saying little about the challenges tomorrow’s children and teenagers will face in a world of global warming, resource scarcity and extreme inequality.
UNFPA is more concerned about maintaining the human-rights terminology of the 1990s than in engaging in a realistic discussion on how to best secure reproductive health and basic sexual rights in the current global context, which increasingly challenges the basic values the institution is based on.
WHO’s one big idea of the past decade, ‘Universal Health Coverage’, is increasingly being promoted in a way that forces associations with ‘health for all’, a philosophy so general – and so cut off from economic reality – that it scorned any specific ‘vertical’ initiatives for nearly two decades while it searched in vain for the one ‘grand solution’.
The UN is at its most effective when its leaders set bold agendas and cajole member states to follow. That is how the Expanded Programme on Immunization, smallpox eradication and the Tobacco Convention became reality. Today’s leaders are too busy second-guessing what would please their member states, and worrying about what the other agency heads are up to, to form bold ideas, much less push them through to realization.
This is the first in a series of expert comments offering different views on global health governance, leading up to the publication of the Centre on Global Health Security's Working Group on Governance report in spring 2014.
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