How must the health and AIDS architecture be modernized to
achieve sustainable global health?
This report summarises the one-day Think Tank Dialogue entitled How must
the health and AIDS architecture be modernized to achieve sustainable global
health? which took place at University College London (UCL) on 2 December
2013.
The UNAIDS and Lancet Commission, co-chaired by President Joyce Banda of the
Republic of Malawi, African Union Commission Chairperson Nkosazana Dlamini
Zuma and Professor Peter Piot, Director of the London School of Hygiene and
Tropical Medicine, is dedicated to ensuring the effective positioning of AIDS in the
post-2015 development agenda and to generating high profile advocacy for
ending AIDS as a shared triumph of the post-2015 era. The Commission will
table its final report in June 2014.
This Dialogue at UCL forms part of the UNAIDS and Lancet Commission’s
commitment to direct engagement with key thought-leaders in the field of HIV,
global health and sustainable development. The Dialogue was convened by
Professor David Coen, Director of UCL Institute of Global Governance and Dr
Sarah Hawkes, Reader at UCL Institute of Global Health, in partnership with
UNAIDS and Lancet Commission: Defeating AIDS – Advancing Global Health.
The purpose of the day was to facilitate exchange between UNAIDS and Lancet
Commission and key thought-leaders in the field of AIDS, global health,
sustainable development and global governance. Discussion was informed by the
ongoing work of the UNAIDS and Lancet Commission third Working Group on the
AIDS response and global health architecture. This report responds to the
Working Group draft paper and provides a summary of the workshop’s key
messages. The deliberations will directly inform the ongoing work of the UNAIDS and
Lancet Commission Third Working Group on AIDS response and global health
architecture.
A roundtable format covered three thematic areas:
Session 1:
Taking Stock: Opportunities and Lessons Learnt from the AIDS
Response for Global Health Governance
Session 2:
Modernizing the global heath and AIDS architecture: Law,
Institutions, and Public-Private Authority
Pathways to enhancing coherence of the global health
architecture
Session 3:
Attendees
Think Tank Dialogue: University College London
2 December 2013
The one-day dialogue was highly interactive with an overview of the Commission
process and initial thinking on the health architecture debate provided by Dr Kent
Buse (UNAIDS) followed by presentations by Dr Simon Rushton (University of
Sheffield), Dr Helena Legido-Quigley (LSHTM), and Dr Sarah Hawkes (UCL)
opening the three roundtable thematics. The dialogue was attended by officials
from the Rockefeller Foundation, WHO, the Partnership for Maternal, Newborn &
Child Health, DFID, UNAIDS, The Lancet, as well as leading academics,
practitioners and civil society representatives in the field of field of AIDS, global
health, sustainable development and global governance.
Session 1: Taking Stock: Opportunities and Lessons Learnt from the
AIDS Response for Global Health Governance
This session reflected on the current state of the global health architecture, the
achievements of important focal actors such as UNAIDS, WHO and the Global
Fund, but also their shortcomings. It further highlighted the vital role of civil
society in mobilising a movement to end AIDS, as well as the role of the private
sector and markets as providers of health services. Inquiry into the proliferation
of actors engaged in AIDS and global health raised questions regarding the
benefits, costs and viability of system plurality versus simplification. Participants
emphasised the need for clear-eyed reflection on the status quo and the need for
Working Group 3 to elaborate concretely on options, including the possibility of
acquisitions, mergers or abolition of existing global health structures. Any
transition from the AIDS response into a more systemic optic on health should be
accompanied by safeguards to ensure that gains made in relation to AIDS
governance and services are not lost.
Summary of discussion

Critical engagement is required in assessing the legacy of the AIDS response;
a focus on success must be matched by analysis of how dysfunctionality is
produced and reproduced.

The AIDS response is emblematic of a revolution in international relations,
especially international law with respect to moving beyond inter-governmental
domains of legal practice.

It is important to consider the fundamental principles which have underpinned
the AIDS response and global health agenda. Can architectural reform at the
global level affect positive health outcomes in local jurisdictions if this
objective is framed in terms of the principle of social justice?

The AIDS response has gone some way to putting people at the centre of
governance arrangements. This should inform the guiding principles of any
future architecture, especially with a view to enhancing global accountability.

We need to critically evaluate the degree to which an internal ‘emergency’
logic of the AIDS response can be scaled up to global public policy on health
more widely. A crisis frame cannot accommodate the full spectrum of health
(e.g. prevention).

The impact of lines of command and control within UN structures for UNAIDS
operating under ECOSOC jurisdiction merits examination. What are the
benefits and trade-offs in being accountable to this member state body as
opposed to the UN General Assembly or other configuration(s) of oversight?
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2 December 2013

There are opportunities for the AIDS agenda to shape global health responses
– both in terms of treatment/management and prevention. For instance, the
AIDS response has lessons for the emerging agenda of universal coverage and
addressing the social determinants of health, particularly NCDs.

The development of the multi-level and multi-scale AIDS response
architecture has evolved rapid, organically and is largely uncoordinated. This
has produced an unusually dense arena of interactions and the benefits of
pluralism (innovation, risk-tasking, entrepreneurialism etc). A downside of this
development, however, is widespread transaction costs as well as venueshopping and agenda-setting by donors.

CSOs have served as both activist partners but also independent arbiters in
holding the AIDS response to account – this dual role should be preserved.

The benefits and pitfalls of private sector partnership in global health provision
need to be more evidence-based. Progressive private sector engagement on
the AIDS response (e.g. differential pricing) may be the exception rather than
the rule.
Session 2: Modernizing the global heath and AIDS architecture: Law,
Institutions, and Public-Private Authority
It is as if we are taking driving lessons. Although we are in the driver’s seat,
someone else applies the accelerator or brake.
HIV CSO representative, Malawi
This session focused on mapping out the contemporary global health sector in
terms of key actors, structures and processes. Participants focused, in particular,
on understanding the role and responsibilities of different actors and the potential
for comparative advantage to be identified. Key tensions were also explored. For
instance, WHO may have the authority to create global public goods in legal
form. However, allocation of resources is often divorced from the rule-making
process. A key deficit in the current architecture is a robust monitoring and
accountability arrangement. As indicated in the above quote, tensions also
emerge in the interface between global and local health stewards, with local
suppliers of public goods excluded from decision-making. A key question to be
addressed is why mechanisms at the country-level have not worked as intended.
IHP may offer insight into faultlines which must be overcome to enhance
harmonisation. A key deficit in the current architecture is dedicated institutions
capable of holding the private sector to account for health outcomes. As the
health agenda widens out to include non-communicable diseases, the role of the
private sector (for good or ill) will be amplified.
Summary of discussion

The formal architecture in global health is very fragmented; key issues in this
regard include the conceptual framing of the domain (pluralism,
networked/nodal governance etc) as well as issues of subsidiarity (how it
works out at the domestic level).

IHP has struggled to align rules to safeguard accountability at international
level with domestic frameworks. This has produced tension for donors who
demand a clear line of sight between investment and results.
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2 December 2013

A degree of plurality is probably inevitable. What has been the impact?
Hierarchy may encourage capture by powerful actors but plurality may also
allow powerful actors to divide and rule.

Reform of the global health system needs to be problem-oriented.
Identification of problems should not be left to insiders; it must also
incorporate the experience of the system by outsiders.

Soft law standards, codes of conduct, and models of best practice should be
given more visibility as we move towards expansion of a legal and prescriptive
framework to underpin the advancement of global health.

The shifting composition of CSOs also requires attention, especially with
regard to the growing gap between transnational CSOs and the constituencies
they claim to represent. Who are the authentic bottom-up advocates for
reform?

There is significant fragmentation at the top (plurality of international health
stewards) and bottom (among in-country CSOs), especially in terms of
agenda-setting and competition over goals. Health sector CSOs are often
focused on issue-specific advocacy undermining coordination. Example: the
issue of sexual reproductive health is often framed either as a gender or
health issue when in fact it is cross-cutting.

Understanding the political economy of incentives which drive behaviour in
global health and challenging prevalent assumptions is essential. Why do
governments feel compelled to engage globally?

WHO must overcome resistance by member states to engagement with a
wider range of stakeholders including CSOs, and facilitate their participation in
decision-making forums.

The private sector and, in particular, the pharmaceutical industry, are key
players in global health service delivery. However, caution must be exercised
in applying market logic to public interventions, especially in terms of their
distributional consequences.
Session 3: Pathways to enhancing coherence of the global health
architecture
This session probed concrete options for reforming the global health architecture.
Participants expressed the viewpoint that the WG 3 draft paper provides a useful,
if wide-ranging, diagnosis but stops short of presenting solutions. Concern was
also expressed that the limited list of functions proposed as a basis for the
division of labour in any new architecture did not have traction among reform
stakeholders. To this end, the group proposed framing the discussion in terms of
four alternative (and potentially overlapping) future scenarios:
1. Market mechanism (evaluation of organisations on basis of operation
efficiency)
Scenario 1 is based on the idea that donors will remain under pressure to
demonstrate value for money and therefore organisations which can deliver on
this metric (particularly related to the MDGs and/or the SDGs) which will be
rewarded. Inefficient and expensive organisations fail. A competitive market
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place focused on best value for money, marshalled by MAR and MOPAN, sets the
parameters for this possible future.
2. UN as legitimate focal actor (recognition of the UN as legitimate
multilateral producer of global public goods)
Scenario 2 envisages a new multilateralism which seeks to accommodate a
rapidly changing world and new opportunities and challenges (e.g. decline of
ODA, the rise of emerging economies, and shifting geography of poverty). Donor
financing packages increasingly give way to diverse providers of technical
assistance. A multi-sectoral rules-based global health system is nevertheless
required to uphold health rights and obligations. The provider of these global
public goods (independent expert bodies etc.) must be regarded as a politically
legitimate steward actor – a role reserved in this scenario for UN agencies.
3. Limited consolidation focused at country-level (build on partial success
of IHP in aligning incentive structures at all levels)
Scenario 3 is based on the premise that serious change at the global level is
politically difficult due to vested interests. As such, a dense arena of
organisations remains fragmented with little or no mergers, acquisitions or
abolitions. The scale of the challenge leads to renewed emphasis on coherence
at country-level through Paris/Accra/Busan rules combined with IHP+ and H4+ to
deliver. Sustained high-level political engagement will be crucial if this
programme of action is to be viable over the long-term.
4. Form follows function (design organisations to address well-defined
goals, possibly the SDGs)
Scenario 4 follows the example of the WG draft paper whereby reform of the
architecture of any future global health system is undertaken in light of specified
functions and careful analysis of the comparative advantage of existing or new
organisations to deliver on their assigned task. A key stumbling block for
realising this scenario is convincing the governors of existing organisations to
narrow or change the role of the bodies over which they exert influence. There is
also a risk of over-prescription in delegating discrete tasks to individual
organisations as opposed to acknowledging complementarity across functions.
Scenario-building can assist in identifying parameters of current decision-making
and drivers of entrenched behaviour (especially around funding). It can also
open up a series of interrogatives for evaluating pathways to future success (for
instance, implications for coordination across sectors, political legitimacy and
access to a wide range of stakeholders, among others). Further caveats
introduced at the session included the complication of objectively measuring
outcomes. Value for money may obscure broader health achievements (healthy
lives are difficult to reduce to single unit measures). Participants offered their
thoughts on incremental steps towards reform but also cautioned against ‘false
promise’ of quick wins given the political complexity of the enterprise. In turn, a
probing line of inquiry queried whether enhancing coherence was the
decisive/variable/most productive framework through which to evaluate the
global health architecture.
Summary of discussion
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2 December 2013

Scenarios require stakeholders to think through consequences of existing and
alternative global health structures. A cursory analysis would conclude that
control of disbursement of financing is a principle driver of behaviour. One
outcome of financial fragmentation is dense interaction but limited institutional
entry into governance. The waning importance of ODA will have consequences
for driving behaviour.

A Framework Convention on Global Health (FCGH) could serve as the basis for a
multi-sectoral rules-based global health system based on principles of the right to
health, equity, gender-parity, accountability, and rule of law. Doubts were
expressed on the feasibility of achieving consensus.

A pragmatic approach may accept that actors like the Global Fund are here to
stay. The question is then how to enhance their operations, especially at the incountry level. Recognition is required that “variable geometry” is needed, with
models tailored to individual country interventions.

One approach to aligning incentives around reform is to survey demand of donor
countries. Orthodox demand was financed by LICs but increasingly, emerging
economies and MICs (China, Brazil and India) are looking to the international
system and UN for better data and systematic and strategic analysis of evidence
to inform country-level policy initiatives on health.

To serve as a sector focal actor, WHO must identify its comparative advantage
(rule-setting, implementation etc). However, there is little agreement on where
this advantage lies.

While the many costs of incorporating UNAIDS into WHO structures were
enumerated (AIDS is not a health issue alone; WHO does not have structures to
ensure inclusivity etc.), it was proposed that such a merger could possibly drive
WHO reform in three areas: (1) situate the AIDS agenda within global health
systems optic; (2) mobilise WHO to address the structural determinants of global
health; (3) reduce transaction costs and streamline ODA financing.

One point of departure for questions of coherence is ODA. However, if non-ODA
private funding is taken into account the debate shifts away from coherence to
relevance. WHO, and other international actors, need to balance concern for
coherence with strategic repositioning.

Reform is a fundamentally political exercise. There may be a functional case for
merger between the Global Fund and GAVI as primary multilateral channels.
However, likelihood of achieving consensus on such a proposal is low.

Institutional innovation could include a resolution dispute body in the global
health sector, equipped to arbitrate in disputes over access to medicine. Such a
body would not be a court. Rather, it would be similar to the World Bank
inspection panel.

Drawing on experience elsewhere in the UN system, prominence should be given
to establishing an independent accountability arrangement within the global
health architecture. The Commission on Information and Accountability for
Women's and Children's Health, co-chaired by President Kikwete (Tanzania) and
Prime Minister Harper (Canada), recently recommended that such a body be
established in relation to MDGs 4 and 5. The UN Secretary-General adopted this
recommendation and established the independent Expert Review Group (iERG),
which reviews the commitments and performance of all stakeholders in relation
to women's and children's health. The Commission’s recommendation, and the
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2 December 2013
experience of the iERG, could usefully be taken into consideration when reimagining enhanced accountability within the global health architecture.
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