Global Level Research Overview


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

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Global Level Research Overview

  1. 1. INCO- Global Health Initiatives Overview of Global Level Research coordinated by theInstitute of Tropical Medicine, Antwerp INCO-GHI COHRED Satellite Session Cape Town, 23 April, 2012
  2. 2. An overview of the research areas2. GHIs and Global Health Governance - Complexity - Health Systems Strengthening - From GHIs to Health Exceptionalism4. 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. 3. Global Health Governance - ComplexityResearch ObjectiveOverall: 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 AllianceFocus: 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 codingKey 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. 4. Governance - Health Systems StrengtheningResearch 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 analysisOutput:-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 7-16Book 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. 5. Governance- Health ExceptionalismResearch 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 reviewOutput:-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. 6. Impact of GHIS on financing/sustainabilityCrowding Out of Domestic ExpenditureResearch 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 analysisOutputs:- ‘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. 7. Impact of GHIS on financing/sustainabilityHuman Resources for HealthResearch 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 EthiopiaMethodology:- 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. 8. The right to health and global health obligationsResearch 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 RapporteurHow 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 interviewsOutput: (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. 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. 10. Section one – the right to healthInternational 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. 11. Section two – The Global FundTo 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 workTwo key features of the Global Fund for our analysis5. The structure of the Board6. Its emphasis on transparency – e.g. of donor contributions 11
  12. 12. Section three - transnational legal processThe 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. 13. Section four - Analysis1. It is particularly incumbent’ → not a matter of charity or political choice2. ‘States parties and other actors in a position to assist’ → shared responsibility, burden sharing needed3. ‘Enabling developing countries’ → only to countries that lack domestic capacity4. ‘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. 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. 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. 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. 17. Ongoing activity2012 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