Report of Rachel Hammonds (ITM) presented at the COHRED forum 2012 on the INCO-GHI research project

1. INCO- Global Health Initiatives
Overview of Global Level Research
coordinated by the
Institute of Tropical Medicine, Antwerp
INCO-GHI COHRED Satellite Session
Cape Town, 23 April, 2012

2. An overview of the research areas
2. GHIs and Global Health Governance
- Complexity
- Health Systems Strengthening
- From GHIs to Health Exceptionalism
4. Impact of GHIS on financing/sustainability
-Crowding out of domestic expenditure on health
-Human resources for health* (country level)
3. Impact of GHIs on the legal obligation to cooperate and provide health
development assistance (in conjunction with the University of Antwerp
Law Faculty)
2

3. Global Health Governance - Complexity
Research Objective
Overall: To identify and evaluate how a complex adaptive systems model enhances understanding of the evolution of Global
Health Initiatives (GHIs) that impact on health systems in sub-Saharan African countries, including Global Fund &
GAVI Alliance
Focus: What insights can a complex adaptive systems model provide for global health governance?
Research Methodology:
• Stakeholder mapping and interviews: Semi-structured in person and phone interviews with key informants
• Thematic Analysis: Transcription, anonymising and coding
Key Finding: It offers a framework for understanding developments in global public health governance over the past two
decades and ways of accessing this complexity through local points of engagement.
Output:
‘Understanding global health governance as a complex adaptive system’ published in Global Public Health, 28 April
2010
3

4. Governance - Health Systems Strengthening
Research Question:
How have GHIs engaged with the health systems strenthening (HSS) agenda including donor alignment/aid
effectiveness efforts (e.g. The Paris Principles)? Expanded to include the Health Systems Funding
Platform.
Methodology:
-literature review, 2-stage key informant interviews, transcription, anonymising, coding, thematic analysis
Output:
-policy briefs on HSS and GHIs – updated in October 2011
-discussion paper ‘Harmonization, Global Health Initiatives and Global Governance’
-peer-reviewed articles including
• ‘Linking programmes and systems: lessons from the GAVI Health Systems Strengthening window.’
2010 Tropical Medicine and International Health 15-2;
• ‘The Health Systems Funding Platform: Is this where we thought we were going?’2011 Globalization
and Health 7-16
Book chapter:
The Alignment Dialogue: GAVI and its Engagement with National Governments in Health Systems Strengthening,
Partnerships and Foundations in Global Health Governance, Palgrave MacMillan International
Political Economy Series, published spring 2011
4

5. Governance- Health Exceptionalism
Research Question:
Overall: What lessons can global health learn from AIDS exceptionality?
Focus: Can a key principle of AIDS exceptionality, open-ended international financing
to complement domestic financing, be extended to global health?
Methodology: literature review
Output:
-Applying the principles of AIDS ‘Exceptionality’ to Global Health: Challenges for
Global Health Governance, Global Health Governance, (Fall 2010)
- Global Health in Search of a Global Social Contract - ITM Working Paper, 2011
5

6. Impact of GHIS on financing/sustainability
Crowding Out of Domestic Expenditure
Research Question:
Does (disease specific) international health expenditure “crowd out” domestic
government health expenditure in sub-Saharan African countries?
Methodology:
- 3 phases including literature review, stakeholder interviews and data analysis
Outputs:
- ‘Crowding out’: a relationship between international health aid and government health
funding too complex to be captured in averages? published in the Lancet, April 17, 2010
- includes policy recomendations regarding how to lessen possible crowding out (e.g.
improve aid predictablility, long-term health compacts, expand mandates of GHIs)
6

7. Impact of GHIS on financing/sustainability
Human Resources for Health
Research Questions:
Overall: What is the impact of HIV specific funding and programmes on non-HIV-related health services and health systems?
Focus: What are the effects of ART scale-up interventions on human resources policies, service delivery and general health
outcomes? The cases of Malawi and Ethiopia
Methodology:
- Compilation of data between 2004(5) and 2009 and use of a conceptual health systems framework for the analysis.
- The major changes in human resources policies as an entry point to explore the wider health systems changes.
Key finding
-In both countries the need for an HIV response triggered an overhaul of human resources policies. As a result, the health
workforce at health facility and community level was reinforced and an improvement in overall health outcomes was
observed. In both countries this required that the different health partners acknowledged and capitalized on these
interactive effects when planning and implementing health activities.
Outputs:
• ‘Positive spill-over effects of ART scale up on wider health systems development: evidence from Ethiopia and Malawi’
Journal of the International AIDS Society 2011, 14(Suppl 1):S3 (6 July 2011)
• ‘Tackling Health Workforce Shortages During Antiretroviral Treatment Scale-up - Experiences from Ethiopia and
Malawi’ Journal of Acquired Immune Deficiency Syndromes 2011 7

8. The right to health and global health obligations
Research Question:
“if there is no legal obligation underpinning the human rights responsibility of international assistance and cooperation,
inescapably all international assistance and cooperation is based fundamentally upon charity” former UN Special
Rapporteur
How and why might the existence of a tool like the Global Fund to Fight HIV, Tuberculosis and Malaria
contribute to the acceptance of obligations of international assistance and cooperation in the field of
health?
Methodology:
-literature review; review of case law and statutes, international treaties,19 semi-structured key informant
interviews (EU, Belgium, US) transcription and thematic analysis of interviews
Output: (in process)
-article in peer-reviewed journal on the impact of the Global Fund on the evolution of global health from
charitable to legal obligation. Examining the lessons the Global Fund experience offers for helping to
delineate multi-stakeholder multi level responsibility for global health assistance.
8

9. Summary
• We are focusing on how and why states move towards compliance
with international human rights law obligations
• Focusing solely on compliance related behavior and speech, would
fail to capture the normative effect of international human rights law
on current practice, as it moves along the path towards or away from
acceptance of global health obligations.
• Our analysis is guided by the work of former Yale Law School Dean
Professor Howard Honghu Koh on transnational legal process and his
tripartite framework of ‘interaction, interpretation and
internalization’ help provide insights into what Berman terms “the
long process of rhetorical persuasion.”
9

10. Section one – the right to health
International Covenant on Economic, Social and Cultural Rights (1966)
• Article 2 on general obligations
• Each State Party to the present Covenant undertakes to take steps, individually and
through international assistance and cooperation, especially economic and technical,
to the maximum of its available resources, with a view to achieving progressively
the full realization of the rights recognized in the present Covenant by all
appropriate means, including particularly the adoption of legislative measures.
General Comment 14 on the right to health (Article 12) of the Committee
on Economic, Social and Cultural Rights (2000)
• “For the avoidance of any doubt, the Committee wishes to emphasize that it is
particularly incumbent on States parties and other actors in a position to assist, to
provide “international assistance and cooperation, especially economic and
technical” which enable developing countries to fulfil their core and other
obligations” (article 45)
10

11. Section two – The Global Fund
To examine the extent to which the Global Fund has or has
not shifted (changed) the basis on which
governments/institutions make decisions about health
ODA and the way in which different stakeholders
approach their work
Two key features of the Global Fund for our analysis
5. The structure of the Board
6. Its emphasis on transparency – e.g. of donor contributions
11

12. Section three - transnational legal process
The process of interaction generates new norms which are
interpreted, enforced and internalized.
For our analysis the salient feature of transnational legal
process is the fact the theory embraces the normativity of
the process.
12

13. Section four - Analysis
1. It is particularly incumbent’ → not a matter of charity or political
choice
2. ‘States parties and other actors in a position to assist’ → shared
responsibility, burden sharing needed
3. ‘Enabling developing countries’ → only to countries that lack
domestic capacity
4. ‘Fulfil core and other obligations’ → not limited to AIDS, TB and
malaria
We already know the Global Fund scores poorly on the fourth
element. But how does it score on the first, second and third
elements?
13

14. Section four - Analysis
‘States parties and other actors in a position to assist’ → shared responsibility, which
implies a form of burden sharing is needed
The Global Fund pools donor resources which allows for a form of burden sharing.
As the Global Fund is highly transparent activists know what there governments have
pledged and what they have paid.
We wanted to understand whether the experience of activists working with donors and
multiple other stakeholders on the Global Fund, including the Board, would
contribute to a sense of burden sharing. We also sought to understand whether or
not they saw the Global Fund as inappropriate tool for discharging a common
responsibility. We wondered how the process of interaction and peer-pressure on
countries to pay their pledged contributions would impact on the notion of a shared
responsibility – perhaps a step towards generating a new norm?
14

15. Section four - Analysis
‘States parties and other actors in a position to assist’ → shared responsibility, which implies a
form of burden sharing is needed
We asked the interviewees whether their experience with the Global Fund has fostered a sense of
burden sharing between donors.
A representative of an American NGO noted that “There was a premise in the original formulation of
the Global Fund that the US would pay a fair share of the global cost, and that is was based on some
other equitable contribution assessments.”
A European NGO representative noted that “One of the instruments in which the burden sharing is
doing very good work is the Global Fund. It is a very concrete institution with a process that permits a
kind of accountability. It’s not enough but it’s kind of a base.”
One former member of the US administration stated that “I think the notion of peer pressure is a
figment of people’s imagination.”
A European NGO representative commented on the limitations of peer pressure “why should
France pay double of their fair share because Japan is not paying, this kind of pressure could be more
normal, more accepted in diplomacy because in my conversation with some Spanish diplomats they say, “
I can’t say Japan oh pay because I paid.” And I think it’s first of all, it’s an issue of culture.”
15

16. Section four - Analysis
‘States parties and other actors in a position to assist’ → shared
responsibility, which implies a form of burden sharing is
needed
• Interact – new norms?
• Interpret - attempt
• Internalise - no
16

17. Ongoing activity
2012 Dissemination of Findings Through:
Conferences/workshops
• April 2012, Geneva Health Forum, Switzerland
• April 2012, COHRED– Global Health Forum, Cape Town,
South Africa
• July 2012, Peoples’ Health Assembly, Cape Town, South
Africa
• October 2012, 2nd Global Symposium on Health Systems
Research, Beijing, China
17