Gavi, the Vaccine Alliance, one of the world’s largest global health initiatives (GHI), began in a UNICEF basement with five staff members. Nearly 25 years later, Gavi has grown to be one of the most influential players on the global health stage, driving solutions to major global health challenges.
But some global health financing experts say large, non-UN, multilateral health agencies like Gavi and the Global Fund need to gradually devolve their functions to countries and move towards cheaper, more country-based institutions.
The Geneva Institute of Advanced Studies Candid conversation The future of the GHI will be discussed at the 77th World Health Assembly, in conjunction with the upcoming “Replenishment” campaign by Gavi and the Global Fund.
The GHI has been accused of fragmenting global health efforts, challenging the authority of the World Health Organization (WHO), and prioritizing donor and private sector interests while avoiding accountability.
Great results but lack of transparency
Gavi, the largest of these GHIs, and the Global Fund have “really challenged the way the traditional multilateral system works through the World Health Organization,” said Professor Katerini Storeng from the Centre for Development and Environment at the University of Oslo.
“Specifically, they did so by giving additional seats to commercial businesses, civil society organizations and charitable foundations,” she said.
This innovative public-private partnership has “radically reshaped global health governance, placing private sector principles such as innovation, technological solutions and the protection of intellectual property rights at its heart,” Ståleng said.
Not only did the GHI bring a private sector perspective to global health financing, but the model was “immediately embraced,” according to Ståleng. One of the most recent examples of the application of this model is the global COVAX campaign led by Gavi during the COVID-19 pandemic.
But Stölleng noted that the pandemic has rekindled old debates, including that these partnerships are dominated by a few powerful GHIs and the “clear conflicts of interest that arise from the inclusion of for-profit actors in the formal institutions of global health governance”.
Experts repeatedly call for greater collaboration among global health partnerships and greater alignment with national health plans and priorities, but some reject these calls for incremental change and instead call for more fundamental reforms or even consolidation of current structures.
According to Antoine de Benji Puyvalle, a postdoctoral researcher at the Centre for Development and Environment at the University of Oslo, three main developments have completely changed the GHI’s landscape: bureaucratisation, expansion of powers and changes in collaboration with other partners.
GHI is moving from a federation to a fully independent organization, and its mission is expanding. In addition, Puyvalley said the budget is “Astronomically” grew threefold between 2005 and 2015, with an increase in staff numbers and a physical presence in Geneva, a global health hotspot.
The CEOs of these organisations are now public figures, and their missions have expanded beyond their original remit to encompass a wide range of goals – Gavi, for example, has expanded beyond vaccinations to include diagnostics, Puyvalle noted.
“We see a path forward from vaccinating children to strengthening health systems,” he said. But the problem with this growth is a lack of accountability. “Is the board in control?”
“Going forward, it would be wise for these partnerships to think of new ways to hold each other accountable, coordination mechanisms that go beyond the traditional way of being governed by their own boards. Otherwise, accountability will be very difficult to achieve,” Puyvalley concluded.
The Global Fund is committed to ensuring that its programs 59 million lives lost since 2002and has made great progress in reducing deaths from HIV, tuberculosis and malaria. Figures for 2022 show a 22% increase in HIV prevention services compared to 2021, and a 26% increase in the number of people diagnosed with and treated for tuberculosis.
Calling for transparency and accountability
According to Mercy Mwangangi, director of health systems strengthening at AMREF Health Africa and former co-chair of the Future of Global Health Initiatives, five key strategic shifts are needed to increase transparency and accountability in these GHIs.
These are investing in basic health care, playing a catalytic role in strengthening domestic resources, championing equity as mandates are expanded, achieving strategic and operational coherence, and mobilizing research and development.
These five changes are: Lusaka Agendaan international multi-stakeholder dialogue.
Mwangangi noted that the Global Fund and Gavi currently have a joint partnership on malaria vaccines and health systems strengthening, but asked, “How do we ensure that these changes translate into implementation in countries?”
She stressed the need to keep country-level transformation and implementation at the forefront through strengthened partnerships, saying, “otherwise we will continue to go in circles.”
Mwangangi also called for broader adoption of the Lusaka Agenda to give countries greater voice and ownership in the GHI ecosystem, but was optimistic about GHI reform.
“The council has actually taken this issue upon itself and shown interest in the Lusaka Agenda,” she added.
But Anders Nordström, a founding member of the Global Fund and former director-general of the WHO, argued that much needs to be done to improve the transparency and accountability of the GHI.
“The Global Fund’s board should actually discuss the annual performance report. I mean, in business, that’s one of the core responsibilities of the board. They should approve the annual report.”
“That’s not what happens at the Global Fund. They approve the annual financial statements. There is no connection between how the funds are spent and the annual report. So the annual report doesn’t have financial figures. The annual report is actually very good, but the board doesn’t include it in their discussions.”
Nordstrom further explained that once the board does this, “it can discuss the efficiency and effectiveness of the use of funds.”
Independence and political responsibility
In countries that have historically received support from the GHI, there are growing concerns about the independence of their health systems.
“Why should an initiative like Gavi buy our basic needs?” asked Justice Nonvignon, Director of the Health Economics Unit at the Africa CDC and Professor at the Department of Health Economics at the University of Ghana.
Nonvignon argued that countries like Ghana needed to fund stronger health operations domestically and move away from dependency.
Countries will need to provide domestic resources to purchase these goods rather than relying on the GHI to meet basic needs. Syringe Nonvignon argued that it relies on medicines and vaccines.
These countries have the means to prioritize funding for health care, Nordstrom added.
“Resources are abundant,” he said, noting that when he worked in Sierra Leone he was told, “It’s a very rich country, rich in diamonds and rare minerals. But where is the money?”
Mwangangi, who works closely with the Kenyan government, said it will be extremely difficult for African countries to break away from this dependency.
“Unless there is a sunset clause, unless there is a mandatory transition plan or further mandatory graduation plan, the Treasury is not going to act,” she said.
Nonvignon said reducing aid dependency would be difficult in the short term but was essential to making countries more resilient and able to act quickly in emergencies.
“Cholera is devastating large swaths of Central and Southern Africa. When is the time to send proposals to foundations based in Washington DC or Geneva?” asked Nonvignon.
“Why is the Global Fund in Geneva and not Nairobi? Why is the Global Fund in Addis Ababa and not Geneva? Because that gives the fund enormous power.”
Nordstrom responded by pointing out that many of the global health initiative ecosystems are highly politicized, and “the power lies not with the secretariat or the directors, but with the governments that provide the funding.”
“I’m worried that the epidemiology is wrong. The vast majority of people are dying from non-communicable diseases. And the global health partnership and the community is not addressing that at all,” he said, adding that the GHI community Impact of climate change.
Will the GHI be abolished by 2030?
Nonvignon suggested the GHI be phased out by 2030 because it has a “fundamental design flaw” in that it was established with no end date in mind.
“Member states’ hopes are starting to grow [of Africa CDC] We need to encourage countries to take more responsibility… to invest money.”
He noted that the pandemic will encourage countries to increase domestic spending on health, improving long-term fiscal sustainability, but cautioned that reducing GHI aid will not mean philanthropy will fill the gap.
African countries “Step upHe also said he would promote “peace and stability” through regional groupings such as the African Union.
Mwangangi said putting “responsibility” on countries themselves would help build global health self-reliance, but countries would need to fund their own health activities domestically.
While the end date may seem extreme to donors, it would at least create space to discuss the sustainability of the GHI and countries’ ability to find footing in health financing.
Image credit: S. Samantaroy/HPW, GAVI, Global Fund, Africa CDC.
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