Update: You can find the response of the FGHI co-chairs to our statements here.
The Future of Global Health Initiatives (FGHI) project, funded by the Wellcome Trust and chaired by Norway and South Africa, released its main report in August 2023 and this week is set to host a high-level discussion at Wilton Park in the UK with a number of key actors including a few community and civil society representatives.
The report on Global Health Institutions (GHI’s) had been highly anticipated by health advocates who looked forward to the opportunity for a productive, in-depth discussion of how to approach a reform of our global health systems. The COVID-19 pandemic continues to expose cracks in our current system, and there remains a lack of clarity on how they should be filled. GFAN (Global Fund Advocates Network) was in New York for the United Nations General Assembly and the three health high-level meetings (HLMs), and the FGHI report was mentioned by government representatives at event after event.
The report was built on the basis of extensive consultations with experts in Global Health from a diversity of backgrounds: government, academia, civil society, technical agencies and funders. The report includes in its scope the Global Fund, Gavi, Unitaid, FIND, CEPI (Coalition for Epidemic Preparedness Innovations) and the Global Financing Facility, which it collectively refers to as “Global Health Initiatives” (GHIs), but mostly focuses on the Global Fund and GAVI.
Given the tight timelines from a January 2023 start date to a July 2023 completion of the report, the authors of the report made a sincere attempt to consult as part of their approach. However, it leads us to our first concern: though the methodology is sound, the way the final product conveys the information captured across these consultations is an issue – in particular, all answers are fully anonymized to ensure frankness, and merged as if all the separate discussions took place as one continuous process which it did not.
This has two significant and concerning effects: it flattens the distinction between consensus and disputed arguments and leaves the reader with no ability to understand whether particular inputs were representative of a consensus, a majority position, or the thoughts of a single person – and it isn’t always clear the perspective they may be speaking from.
Reading the report, what GHIs have achieved over the past 20 years feels glossed over, because all participants more or less say the same things: millions of lives have been saved, treatments have improved and been made more available, infections have been averted, etc. When it comes to concerns with the GHIs however, everyone has a different axe to grind, resulting in the report being a long laundry list of issues, contrasted with only a few upsides that do not do justice to the real-world impact of GHIs.
Second, though linked to the issue above, there is a lack of coherence across the report. The content of the consultations is reported rather than analyzed, resulting in views which are incompatible being presented side by side and as equally valid and factual. Some participants think GHIs are too narrow in focus and distort national priorities and budgets towards issues falling within their mandate (ATM, vaccines, etc.). Others see the GHIs as overextended after years of reaching beyond the confines of their mandate. Others want GHI’s to be flexible and to “fill the gaps”. These points of view all have their merits, and there might be a way to articulate them together. As presented in the report though, they are incompatible. GHIs cannot be criticized for both being too focused on narrow mandates and too bent on expanding them – and the report presents both the perspective of GHIs needing to “stick to their mandates” and yet also, fill gaps such as with non-communicable diseases as if they were equally based on extensive analysis of what has been done and what is possible and what is needed.
It must be said as well that there are factual errors in the report that have not yet been corrected, after a first round of revisions. The final result is one where half remembered statistics mentioned by an informant are printed without additional context or more importantly, correction. Most egregiously, the report quotes a participant saying that 80% of the health budget of Mozambique is for HIV, and later in the report indicates that 80% of international funding in Mozambique goes to HIV – both very different claims. Neither is sourced. Doing our own research, we found that in 2019 Mozambique – a country with one of the highest HIV rates in the world, with an estimated prevalence among adults in 2020 estimated at 11.5% according to the CDC (Centers for Disease Control) (see what we did there?) – received about $445 million in Development Assistance for Health (DAH), among which $196 million was focused on HIV, or 44% according to IHME.
In other words, Mozambique is not a good an example of GHIs distorting priorities, since the enduring high prevalence justifies high investments, and claims suggesting these investments are incredibly lop-sided were not sourced – nor could we find a source to justify the quoted claims.
In reading the report, this leaves us with no real tools for comparison; yes, GHIs pose problems and have issues, like all bureaucracies. The questions it would seem are: is there a pattern of willingness to change and/or adapt and are GHIs significantly worse bureaucracies than some of the alternatives? It is especially important to consider when contrasting the GHIs with development banks and UN (United Nations) agencies – as the report does – which have their fair share of controversies and criticism, and certainly cannot be portrayed as inherently less political or influential.
The lack of any depth of analysis in the report about the importance of increased financing across global health being a real hindrance is a serious challenge. The central question in the report that is touched on only anecdotally is the pros and cons of replenishment models. Two things have happened since the launch of the Global Fund and the rest of the GHIs: funding for global health has skyrocketed, and the share of the Global Fund among that funding has significantly increased. The FGHI report asks, in its first section on the positive impacts of GHIs, whether the funding mobilized by GHIs is new funding. Within health, the answer from these summary figures is clear – there has been a lot of new funding going to health over the past 20 years, and the share of GHIs has grown faster than other channels. If your goal was to see value-for-money and impact for increased funding to GHIs within health; you do not actually have to look far for those results.
The report’s conclusion and recommendations present an interesting challenge to us as communities and civil society organisations – they are interesting and thought-provoking but bear little connection to the actual content of the report, which makes them hard to understand and consider them even when we tend towards vocal critiques of GHIs. The reports recommendations also range from small, easy-to-implement tweaks (more KPIs on partnership, more transparency across GHIs and with implementing governments) to complete overhauls of the global health infrastructure (alignment of replenishment and grant timelines across all GHIs and merger of their country teams).
Is there anything to learn from or take away from the report? Of course. GHIs are not above criticism, and those listed in the report must be taken seriously. Yet, the way they are articulated in the report – or rather NOT articulated – and the fact that several of them are grounded in factually inaccurate or out-of-date data, is a significant issue that should not be ignored.
The report is helpful to identify some questions we see as good framing points. Going forward, three of them strike us as important:
- Disease-focus vs holistic care: GHI’s are increasingly investing in activities that integrate services, strengthen broader systems for health and framing much of their work in terms of potential for impact now and preparedness for future pandemics. There are gaps that need filling and there is more integration that needs to happen – and most of the GHI’s already stand not at the beginning of this evolution, but somewhere along a continuum from early, basic efforts to more sophisticated and nuanced approaches than this report acknowledges.
- Bottom-up design vs priority setting: the Global Fund for example, is, at its core a partnership between donors, implementers, affected communities, civil society, the private sector, foundations/philanthropies and other GHIs; but the recommendations from the report lean squarely towards strengthening the influence of implementing country governments – are they the sole entities responsible for legitimacy and accountability? Country-led and government responses are in fact different, with one being more comprehensive of the expertise that should be brought to bear in making health decisions, and seek to ensure that all benefit and the last mile is reached in an equitable way. Handing more funding over to governments without ensuring broad participation in the collection of evidence/data, analysis, development, implementation and monitoring of work is the old model, a recipe for failure and frankly, a model that GHIs seem better equipped to incorporate than others.
- Impact and effectiveness vs capacity building of existing systems: Poor health outcomes locally are connected to poor system performance; where these systems fail the communities they serve, should GHI’s prioritize their immediate need and, if necessary, bypass those systems? Is there a moral imperative to invest in immediate health improvements with impact in terms of lives saved and steady but more moderate improvements to health systems over time? Or is there an ethical responsibility of GHIs and donors to implementing country governments to build systems for the longer-term with an associated risk and less likelihood of impact in terms of lives saved in the short and medium term? Most likely the answer lies somewhere in between and taking a hard look at how GHIs contribute to capacity building alongside their more immediate impacts in terms of prevention, treatment and care would be welcome and could hopefully move us to where we no longer think of vertical or horizontal approaches, but just the value of the complementarity of different approaches.
These questions and tensions are not new, but it is useful to be reminded of their enduring relevance, and renewed salience in the context of the post-COVID rebuilding of global health infrastructure. We do not believe that the FGHI report contains obvious solutions to any of these tensions, because it refuses to engage with the reality that it is unlikely that a single answer is possible. Instead, these are tensions inherent to the work of the GHIs, and cannot be “solved”, only negotiated, challenged constantly and progressively changed to meet the challenges of an ever-changing set of health needs that are deeply contextual to their specific time and political environment.
A final word on the Global Fund: GFAN and many of its 1000 members globally were actively engaged in the development of the Global Fund new strategy, and we do believe, as the Global Fund has argued, that the new strategy is moving towards addressing a lot of the issues mentioned in the FGHI report. The Global Fund Secretariat has made this argument in its response to the report, and we largely agree. Several other organizations have published written responses to the FGHI report, each bringing a different perspective – we have focused here on the structure and overall argument of the report, without focusing on specific arguments, and some of these responses do so very well. We have found the remarks from the Civil Society and Communities Delegation to Unitaid, and the University of Oslo especially interesting.
— Katy and Quentin