Follow the Money: Global Health Edition
To truly understand power within systems, you’ve got to follow the money. That’s part of what Chelsea Clinton and Devi Sridhar try to do in their new book, Governing Global Health: Who Runs the World and Why? Using four case studies of leading organizations—the World Health Organization, World Bank, GAVI, and The Global Fund to Fight AIDS, Tuberculosis and Malaria—the co-authors explore the financing and structures within these pillars of global health to better understand their impact.
In a recent book launch event at the Mailman School, the authors explained the genesis of the book—the need for a resource that examined, compared, and critiqued issues of global health governance, transparency, and accountability. Clinton, an alumna and adjunct assistant professor of Health Policy and Management at the Mailman School, currently serves as vice chair at the Clinton Foundation in New York, while Sridhar is professor and chair of Global Public Health at the University of Edinburgh’s Medical School in Scotland. Both earned doctorates at Oxford University.
The book distinguishes between older, more traditional multilateral global health institutions, and more recent arrivals. Stalwarts like the World Health Organization (WHO) have more broadly defined goals; they work toward the “attainment by all people of the highest possible level of health;" similarly, the World Bank aims to “alleviate poverty and improve quality of life.” Compare these to the narrower, problem-focused missions of newer, public-private partnerships: GAVI wants to “increase access to immunization in poor countries” and the mandate of The Global Fund is to “attract and disburse additional resources to prevent and treat HIV/AIDS, TB, and malaria.”
The old vs. new comparisons hold true for governance structures as well: WHO and the World Bank are overseen solely by national governments and their representatives; whereas the governance boards of GAVI and The Global Fund include both state and non-state actors like private companies and NGOs. “The enfranchisement of non-state actors is something that the world has really only just begun a grand experiment since the new millennium,” said Clinton.
No matter if a global health organization is old or new, they rely on both state and non-state actors for funding. And while investments in global health have grown exponentially in recent decades, the donor pool has concentrated.
“A large part of the growth in the financing has come from three donors: The Gates Foundation, United Kingdom, and the United States,” explained Sridhar. “While we think of global health as this global activity, with more and more initiatives and with more and more partners, the core financing base has actually narrowed down to three. It certainly makes for interesting and difficult positions for the WHO Director-General and the heads of these organizations when you’re dependent on just a few donors for financing.”
A Question of WHO
Following the money and understanding the power structures behind global health matters when it comes holding these powerful institutions accountable or pushing them to reform.
According to Clinton and Sridhar, WHO is a particularly difficult organization to change due to its lack of transparency: it’s the only one out of the big four that does not have a transparency or open information policy. Donors, while generous, can earmark funds to certain purposes or specific regions of the world, limiting the discretionary ability of the Director-General to carry out the organization’s agenda or to deal with an emerging crisis.
The roadblocks to reform at WHO came into stark relief in the wake of the 2014 Ebola outbreak as seen in their lack of readily available resources and slow response to the crisis. And though promises of change were made, so far, the authors say, very few have been realized.
“It’s notable with WHO: we had an Ebola crisis where over 10,000 people died, and yet nobody lost their jobs anywhere in the organization,” said Sridhar. “It comes back to these issues of accountability and monitoring and trust, and making sure people are held responsible.”
Current WHO Director-General Margaret Chan’s term is up this year, and the World Health Assembly will elect a new leader in May. Could this be a chance to rebuild trust among donors and the public?
“It is a bit of a classic chicken and egg challenge,” said Clinton. “Will donors step up and provide the necessary resources for WHO to do its job, or will WHO have to prove itself more fit for purpose? If it’s the latter, hopefully the world won’t face another crisis like Ebola or Zika in the meantime to remind us once again why it’s so important that the world be more prepared.”