Fault Lines in Global Health – September 14, 2010
Resolved: That the Global Fund to Fight AIDS, Tuberculosis, and Malaria should be transformed to become the Global Fund for Health.
Last Tuesday, the CSIS Global Health Policy Center hosted Ambassador Mark Dybul, former U.S. Global AIDS Coordinator, now of Georgetown University, and Dr. Julian Schweitzer, former World Bank Vice President of the Human Development Network, now of the Results for Development Institute, for its second Fault Lines in Global Health event. (The first Fault Lines event featured Princeton Lyman and Todd Summers debating the sustainability of U.S. bilateral commitments on AIDS treatment.)
Ambassador Dybul spoke in favor of transforming the Global Fund to Fight AIDS, Tuberculosis, and Malaria into the principal global financier for the integrated delivery of health services, as an alternative to the “vertical,” disease-specific programs that have characterized the last decade of global health work. Dr. Schweitzer agreed with Ambassador Dybul on the problems and inefficiencies in global health today but spoke against a transformation or expansion of the Global Fund.
Health Affairs editor-in-chief Susan Dentzer was again a masterful moderator, identifying areas of agreement and disagreement and encouraging energetic debate throughout the session.
Below is my summary of these areas of agreement and disagreement. In a later post, I’ll offer my thoughts on how these arguments fit together and respond to your feedback.
AGREEMENT ON THE DIAGNOSIS
Dybul and Schweitzer agreed that disease-specific programs, which have seen remarkable growth over the last decade, have done tremendous good. They have saved millions of lives, restoring faith in health and development assistance by setting large goals and achieving them.
Disease-specific programs have, however, created silos in global health funding. In turn, silos in funding become silos in delivery. A pregnant woman on antiretroviral treatment who dies in childbirth, observed Dybul, is hardly better off than she would have been without AIDS treatment, and neither is her newborn or her community. Schweitzer echoed this diagnosis, describing freestanding clinics that can only treat a particular disease, as well as cars sitting in Ministry of Health garages that can only be used on particular projects.
Both sides made clear that greater harmonization could produce more health for the dollar. With agreement that integration could break down inefficient and duplicative health systems, the question of the debate became how to achieve it.
Above, video from the debate
DYBUL’S PLAN FOR A TRANSFORMED GLOBAL FUND
To frame his proposal for the Global Fund, Dybul sketched the historical arc of development assistance, from the Cold War geopolitics and post-colonial guilt of the 20th century to the revolutionary agreement on country ownership, good governance, and results-based investments at the start of the 21st. These principles, he said—written into the Monterrey Consensus, Paris Declaration, and Accra Accord—were the evolutionary jump that generated the resources and successes of the last ten years.
Integration, he argued, will be the next genetic leap in the global aid architecture. Currently disease-specific funding from donors forces countries toward fragmented programs and away from comprehensive national health plans; a solution is needed that produces integration at the donor level, allowing countries to submit a single national health plan and receive funding for the entire package of programs.
Dybul proposed three possibilities to achieve this vision, two of which he found lacking. First, current health assistance organizations could do a better job cooperating with one another. While this is already happening to some extent, Dybul discarded this approach because greater cooperation between separate, sometimes redundant organizations could never create true integration. Second, a new organization could be created. Dybul dismissed this immediately as impractical and a bad idea.
The third possibility, which Dybul supported is to transform a current multilateral assistance organization. Dybul argued that the only organization that would succeed in this capacity is the Global Fund, as it was built explicitly to reflect the Monterrey Consensus, Paris Declaration, and Accra Accord. It also could serve as a funding-only organization, leaving specialized technical support to other actors. This separation prevents a conflict of interest where funders are selecting and evaluating their own programs.
Transformed into the principal financier for global health, the Global Fund for Health would sit at the center of a panel, comprising all multilateral health assistance organizations, that would review each country’s integrated health plan. If the plan was approved, it would be funded in its entirety, not disease by disease.
SCHWEITZER’S ARGUMENTS AGAINST A NEW GLOBAL FUND
Julian Schweitzer offered his eight concerns with such a proposal:
First, such a “global quasi-funding monopoly” would not actually leave technical assistance to someone else. A clear divide between funding and technical assistance was the original Global Fund vision, but now, instead of being a lean funding-only organization, the Global Fund has a staff of 600 sitting in one of the world’s most expensive cities. Stakeholders will demand technical capability to use and monitor their money, creating a larger bureaucracy and worse conflict of interest.
Second, even if the new Global Fund was efficient and streamlined, a global health monopoly is a bad idea. As in other sectors, competition of ideas and approaches produces the best results. A single-minded review panel will create homogenous interventions and standards, allowing countries to “teach to the test.”
Third, such a transformation is not feasible. Large bilateral donors, philanthropic organizations, and multilateral development banks will not hand over a large proportion of their resources to a single global health financier.
Fourth, many health outcomes are not tied exclusively to health investments but instead to economic growth, girls’ education, road infrastructure and safety, etc. A Global Fund for Health that worked in these other sectors would duplicate the work of other agencies and multilateral banks, creating more redundancy and fragmentation.
Fifth, integrated external financing would not address the need to reduce out-of-pocket health expenses and establish national health insurance programs.
Sixth, even if such a transformation was possible and a good idea, it would require a radical change in Global Fund governance. The current consensus-driven approach has been a strength of the Global Fund but has come at the cost of its sometimes slow, cumbersome decision-making. Involving many new stakeholders from other sectors will only worsen this tension between consensus and decisiveness.
Seventh, there is already pressure on Global Fund budgets simply to pursue its current mission. The most likely result of an attempt to transform the Fund will be an even larger mandate with few additional resources to spread across it.
Eighth, how effective is the Global Fund? By its count, the Fund has saved 5.7 million lives—no bad feat. But other agencies haven’t used the Global Fund methodology, so we have no actual value-for-money comparisons, which would be a prerequisite to choosing the Fund to be such a monopoly. Preliminary numbers from the World Bank, using the Global Fund’s methodology, suggest that the Bank has saved 13 million lives in the same period—showing the benefit of diverse approaches.
Despite these objections, asked Dybul, what is Schweitzer’s alternative proposal? With agreement on the problem, some action must be taken. Schweitzer said he would provide assistance to recipient countries to manage donors and integrate funds at the national level. Dybul replied that recipient countries will not have enough leverage to make demands of their external donors, making integration at the international level a prerequisite to any such national plans.
As this summary makes clear, our Fault Lines in Global Health event served to initiate debate, not to settle it. Over the course of 90 minutes, Dybul and Schweitzer presented and responded to a wide variety of arguments on each side of the resolution.
We welcome you to continue the debate. Do you find one side more or less persuasive? Do you join or differ in their wide agreement about disease-specific programs? Were there arguments you expected that you didn’t hear?