Global health governance is in many ways proving more innovative and resilient than other sectors in global governance. In order to understand the mechanisms that have made these developments possible, this article draws on the concept of gridlock, as well as on the additional theoretical strands of metagovernance and adaptive governance, to conceptualize how global health governance has been able to adapt despite increasingly difficult conditions in the multilateral order. The remarkable degree of innovation that characterizes global health governance is the result of two interrelated conditions. First, developments that are normally associated with gridlock in multilateral cooperation, such as institutional fragmentation and growing multipolarity, have transformed, rather than gridlocked, global health governance. Second, global health actors have often been able to harness the opportunities offered by three important pathways of change, namely: (1) a significant degree of organizational learning and active feedback loops between epistemic and practice communities; (2) a highly polycentric system of governance; and (3) the increased role of political leadership as a catalyst for governance innovation. These trends are discussed in the context of three case studies of significant political, social and health relevance, namely HIV/AIDS, the 2014 Ebola outbreak and antimicrobial resistance.
BackgroundThe Global Fund is one of the largest actors in global health. In 2015 the Global Fund was credited with disbursing close to 10 % of all development assistance for health. In 2011 it began a reform process in response to internal reviews following allegations of recipients’ misuse of funds. Reforms have focused on grant application processes thus far while the core structures and paradigm have remained intact. We report results of discussions with key stakeholders on the Global Fund, its paradigm of oversight, monitoring, and results in Mozambique.MethodsWe conducted 38 semi-structured in-depth interviews in Maputo, Mozambique and members of the Global Fund Board and Secretariat in Switzerland. In-country stakeholders were representatives from Global Fund country structures (eg. Principle Recipient), the Ministry of Health, health or development attachés bilateral and multilateral agencies, consultants, and the NGO coordinating body. Thematic coding revealed concerns about the combination of weak country oversight with stringent and cumbersome requirements for monitoring and evaluation linked to performance-based financing.ResultsAnalysis revealed that despite the changes associated with the New Funding Model, respondents in both Maputo and Geneva firmly believe challenges remain in Global Fund’s structure and paradigm. The lack of a country office has many negative downstream effects including reliance on in-country partners and ineffective coordination. Due to weak managerial and absorptive capacity, more oversight is required than is afforded by country team visits. In-country partners provide much needed support for Global Fund recipients, but roles, responsibilities, and accountability must be clearly defined for a successful long-term partnership. Furthermore, decision-makers in Geneva recognize in-country coordination as vital to successful implementation, and partners welcome increased Global Fund engagement.ConclusionsTo date, there are no institutional requirements for formalized coordination, and the Global Fund has no consistent representation in Mozambique’s in-country coordination groups. The Global Fund should adapt grant implementation and monitoring procedures to the specific local realities that would be illuminated by more formalized coordination.Electronic supplementary materialThe online version of this article (10.1186/s12992-017-0308-7) contains supplementary material, which is available to authorized users.
Ensuring 'health for all' remains a persistent and entrenched global challenge. G20 governments are in a position to elevate the priority accorded to health, and acknowledge the centrality of health to attaining the SDGs. The authors call on G20 leaders to build nations that are more inclusive and less divided, by: adopting a Health-in-All-Policies approach, prioritizing the most vulnerable, engaging citizens in policy processes, and filling health data gaps.(Published as Global Solutions Paper) JEL I1 I18
Problem The Ebola virus disease crisis in West Africa revealed critical weaknesses in health policy and systems in the region, including the poor development and retention of policy leaders able to set sound policy to improve health. Innovative models for enhancing the capabilities of emerging leaders while retaining their talent in their countries are vital. Approach Chatham House (London, United Kingdom) established the West African Global Health Leaders Fellowship to help develop the next generation of West African public health leaders. The innovative program took a unique approach: Six weeks of intensive practical leadership and policy training in London and Geneva bookended a 10-month policy project conceived and carried out by each fellow in their home country. The program emphasized practice, site visits and observation of U.K. public health organizations, identifying resources, and networking. Strong mentorship throughout the fieldwork was a central focus. Work on the pilot phase began in June 2016; the fellows completed their program in September 2017. Outcomes The pilot phase of the fellowship was successful, demonstrating that this “sandwich” model for fellowships—whereby participants receive focused leadership training at the start and end of the program, minimally disrupting their lives in-country—offers exciting possibilities for enhancing leadership skills while retaining talent within Africa. Next Steps On the basis of this successful pilot, a second cohort of eight fellows began the program in October 2018. The expanded African Public Health Leaders Fellowship has become a central activity of Chatham House’s Centre on Global Health Security.
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