Emergence & Evolution of GHIs Carlos Bruen & Ruairí Brugha Royal College of Surgeons in Ireland
Aims & Methods of StudyAnalysis 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 andnetworks in the evolving design and policy priorities of GHIsMethods•Documentary Reviews•Stakeholder mapping & in-depth telephone interviews of purposivelyselected individuals (n=36) (2009-11)•Recorded, transcribed, anonymised, thematic analysisInterviewee Characteristics•Constituency Affiliation at time of interview•Constituency Crossing•Multiple Roles
Actor-Centered Analysis Health Policy Analysis •Global Health Object of Research: GHIs Governance -New institutions within the field of Global Health •Comparative Governance that drive a global agenda at the country level Institutional Analysis -Comprised of individuals and organizations across multiple constituencies, aim of which is •Network Analysis to address collective action problems •Strategic Action TheoryCf: Adam & Krisei (2007); Fligstein & McAdam (2011); Hein et al (2009);Jackson (2010); Walt & Gilson (1994)
General Overview - Actors in GHIEmergence• Modus operandi rooted in the influence of different stakeholders at the time of GHI formation PEPFAR Global Fund GAVI AlliancePolicy Semi-open - influential small, closed Open - Multiple policy communitiesCommunity Closed - Small policy community within broad issue network policy community in broader issue networkType •Core: Transitional Working Group •Core: PATH, vaccine reps fromKey Actors •Core: US Federal agencies •G8(financial), African govs multilateral institutions, private (symbolic) sector and Gates Foundationin GHI •US Congress negotiations & •Consultations with countries, civil •Reps from European donor orgs NGO/private sector lobbyingdesign soc , private sector (+ traditional •Consultation through personal actors) networks •Global Fund slow in releasing •Need for a ‘war chest’ •Counteract falling priority of finances, PEPFAR as emergency vaccines & UN systems’Cited response and ‘catalyst’. •Address failures of existing weaknesses strategies, incl. UN systemJustification •Soft power focus on Africa •Involve public and private • Involve public + privates •Need to improve coordination of stakeholders stakeholders (eg WHO) in an US agencies ‘alliance’ to get buy-in •‘Lean and Mean’, ‘quick wins’ •‘Lean and Mean’ •1/3 spending for abstinence only •No country presence programs, anti-prostitution pledge & •Worked with (separate to) UN •No country presence but use EPI no funding to needle exchange agencies (immunisation) infrastructureExamples of programs •Focus on 3 diseases, but early •Focus on new and increasedpolicy •System preference for US-NGOs focus on HIV/AIDS treatment scale- access to existing vaccinesoutcomes •Top-down influence on national up •Use performance-based funding reforms •Use performance-based funding •Increased NGO role for service •Greater NGO role in service •Increased NGO role for service delivery delivery delivery and governance
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 StrategicAction 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?
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