The Dynamics of Power Flow From the Global Health Financing Comment on "Power Dynamics Among Health Professionals in Nigeria: A Case Study of the Global Fund Policy Process"

Abstract

This article agrees with Lassa et al. that biomedical paradigms and medical professionals are a dominating force within the policy dynamics of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and that there needs to be greater community involvement in how global health initiatives (GHIs) are adopted, designed, implemented and evaluated. However, we argue that many of the conditions identified are entrenched and perpetuated by how GHIs are financed and the financing modalities employed in Development Aid for Health (DAH), particularly in low resource settings. As a result, the dynamics of power not only flow from traditionally entrenched epistemic authorities but are disproportionally sustained by global health financing modalities that favour particular GHIs over others. As we argue, these DAH modalities can exert forms of power with problematic effects on policy making.

Challenges in international health financing and implications for the new pandemic fund

“…Power dynamics, or more accurately, power asymmetries within countries, and between states and non-state actors, particularly those at international level, are pervasive across global health governance. Through such international financing channels, powerful actors can have a tangible and concrete influence over the direction of agencies, national health system priorities in implementing countries and funding channels for selected implementing agencies [ 15 , 80 ]. This creates a scenario whereby if an implementing country’s government disagrees with the international funder-selected priority area, they risk forgoing financial support.…”

Governance Challenges in International Health Financing and Implications for the New Pandemic Fund

“…Through such international nancing channels, powerful actors can have a tangible and concrete in uence over the direction of agencies, national health system priorities in implementing countries and funding channels for selected implementing agencies [15,79]. This creates a scenario whereby if an implementing country's government disagrees with the international funder-selected priority area, they risk forgoing nancial support.…”

Evolving Power Dynamics in Global Health: From Biomedical Hegemony to Market Dynamics in Global Health Financing; A Response to the Recent Commentaries

“…We concur with Dalglish et al 4 and Parashar et al, 1 that ‘the dominance of medical professionals in healthcare is global, but it takes a particular shape in many low- and middle-income countries due to the imprint of colonialism.’ 2 Johnson argues that an understanding of medical professional power in post-colonial countries can only be achieved by acknowledging the relationship between the medical professionals and their colonial and post-colonial states. 6 In the case of Nigeria, the transmission of power, social status and authority of medical professionals has been through a historic colonial symbiotic relationship between the Imperial state and medical professionals, 7 discoveries in tropical medicine, 8 and more recently (demonstrated in our paper) biomedical epistemic communities.…”

“… 13 In achieving perceived efficiency from health providers, an adoption of performance-based funding, incentive structures, market driven research and vertical approaches has consequently shaped the health market. 2 Brown and Rhodes in their response brilliantly summarised this point as follows ‘Recognizing this helps to explain the donor preference for earmarked funding and vertical programs as well as the bias often given to supply-side clinical and biomedical projects. ’ 2 However,a review of the empirical evidence concerning ‘pay for performance’ incentives by Global Health Initiatives, shows that incentives can have negative effects on the professionalism of health workers in general, leading to a ‘focus only on achieving the explicit targets that are being rewarded at the expense of other important but unmeasured tasks.’ 14 This dynamic has limited the opportunities for community-led participation ‘ ultimately side-lining local expertise and community perspectives.…”

“… 2 Brown and Rhodes in their response brilliantly summarised this point as follows ‘Recognizing this helps to explain the donor preference for earmarked funding and vertical programs as well as the bias often given to supply-side clinical and biomedical projects. ’ 2 However,a review of the empirical evidence concerning ‘pay for performance’ incentives by Global Health Initiatives, shows that incentives can have negative effects on the professionalism of health workers in general, leading to a ‘focus only on achieving the explicit targets that are being rewarded at the expense of other important but unmeasured tasks.’ 14 This dynamic has limited the opportunities for community-led participation ‘ ultimately side-lining local expertise and community perspectives. ’ 2 If this dynamic is left unchecked, we could risk reducing the very idea and values of public health to commodified NPM driven objectives in the form of artificial intelligence (AI) algorithms, consequently, side-lining the community.…”