Agenda-Setting

In the past, global agenda-setting in health took place within the framework of the United Nations (UN)—primarily at WHO and the UN Childrens Fund (UNICEF)—with input from national governments and a few foundations. It was exemplified by iconic programs such as the eradication initiatives for malaria and smallpox in the 1950s–70s. Agenda-setting is well captured by a “punctuated equilibrium” model, in which long periods of relative stability in agendas are sporadically broken by sudden bursts of high-level attention in public and policy circles [8],[9]. Agendas may vary because of crises, such as natural disasters or epidemics, or from recognition of the human and economic costs of inaction, as with noncommunicable diseases [10]. History indicates that these episodes of high attention are fleeting; seizing these brief opportunities to produce lasting change usually requires adapting governance structures to accommodate new actors and interests [11].

Our case study of malaria found that, after undergoing a half-century of fluctuating global attention, malaria re-emerged on the global agenda in the late 1990s. Central to its reemergence was the creation of a novel global governance structure, the Roll Back Malaria (RBM) Partnership, launched by WHO. RBM now includes over 100 organizations including endemic country governments, donors, civil society organizations, the private sector, and academia.

Once an issue garners attention and attracts many new actors and activities, effective governance requires a process for setting an agenda for action within the issue area. Coordination is ultimately essential; however, as several experienced participants in our workshops pointed out, few organizations wish to be coordinated, because of the costs and loss of autonomy entailed. Thus coordination and some degree of harmonization of multiple independent activities are likely to emerge only after the construction of consensus on a widely shared set of rules, roles, and expectations. To get to this consensus, participants must share a clear set of goals and perceive the process as inclusive, transparent, technically credible, and fair.

Effective agenda-setting for action, when achieved, can provide a framework (albeit no guarantee) for coordination at global and national levels. The 2008 Global Malaria Action Plan, which was negotiated within the RBM framework, exemplifies how global agenda-setting for action within an issue area can be achieved [12]. A similar institution, the Stop TB Partnership, has also created a coordinating framework for tuberculosis control.

Underlying such institutional frameworks must be scientifically valid metrics, evidence of the problem's importance, and recognition that tools exist, however imperfect, that could improve health outcomes. Finally, the framework requires that the affected countries and the public, who are ultimately co-producers of health, be represented as key participants [4]. These partnerships, anchored by the legitimacy of the WHO, represent creative approaches to eliciting the broad participation necessary to construct widely accepted agendas and forge consensus at the global level.

Financing and Resource Allocation

International financing and resource allocation for health in developing countries have long been subject to three fundamental questions [13]: (1) How should the priorities of donors be balanced with those of recipients? (2) How should resources be allocated to different diseases or issue areas? (3) How can sufficient investment into health, which has traditionally been underfunded relative to need, be ensured?

In the past, international resources for health flowed primarily through bi-/multilateral donors and WHO with only a few exceptions, e.g., the Rockefeller Foundation. Over the past decade a variety of actors, including philanthropists, advocacy groups, civil society, and public and private sector organizations, have catalyzed an unprecedented increase in the flow of international financing for health [14]. In the case of malaria, funding has increased tenfold [12]. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) represents a model for enabling some coherence in the resource allocation process for its mandated diseases. The GFATM balances two often-competing objectives: providing reassurance to donors by only funding projects adhering to international “best practices,” and demanding that country applications demonstrate meaningful and widespread national ownership [15]. By unifying multiple funding streams and oversight processes, the GFATM also tries to lighten the burden put on national health systems by reporting requirements and lack of coordination among multiple donors—an issue exacerbated by the recent increase in players in the global health system.

While the upsurge of financing for malaria is welcome, it also points to a current governance gap in the overall system: there are no clear norms for how resources should be allocated across different health needs. The Global Burden of Disease and Disease Control Priorities Projects have provided country estimates of years of healthy life lost to illness and injury, identified major risks, and estimated the cost-effectiveness of interventions [16],[17]. However, widely accepted principles on how to translate these figures into resource allocation decisions are lacking. Major discrepancies exist between resources provided for specific diseases and their relative burden, e.g., HIV/AIDS versus chronic diseases, and between the burdens of disease within specific countries and their ability to attract resources to address them [18].

A related question is how to increase funding levels further to meet the full spectrum of global health needs, and how to sustain those levels in the long run. Especially in difficult economic times, it is critical to ensure continuity by insulating finance arrangements to the greatest extent possible [19]. In all World Bank regions, external development assistance represents less than 3% of total health spending, with the exception of sub-Saharan Africa where it accounts for 21% [20]. However, international financing is critical for providing global public goods and for the lowest-income countries that rely on aid to meet basic health needs. Financial fluctuations can be disruptive in all countries, but for the poorest, a sudden drop in aid can be devastating. The long-term sustainability of financing will rest on three elements: (1) demonstrating results; (2) making financing arrangements more politically acceptable by mobilizing more resources from middle-income countries; and (3) developing innovative financing mechanisms that are less vulnerable to politicized budgeting processes. One such innovative model is UNITAID, which purchases health products for use primarily in low-income countries and is funded through national airline taxes. Of the 29 committed UNITAID donors, three-quarters are low- or middle-income countries, emphasizing the idea that all nations—even the poorest—can contribute to sustainable global health finance [21].

Research and Development

In the past, health technologies such as drugs, vaccines, and diagnostics were developed primarily by and for populations in the industrialized world. Today there is increasing evidence of contributions from the South to global health research. Investments in human capacity that began in the 1970s are now bearing fruit as scientists from Africa, Asia, and Latin America take a key role in advancing research, as in the case of malaria [5]. After a period of neglect, there is now a resurgence of R&D aimed specifically at developing new tools for the health needs of developing countries. Since traditional market incentives such as the patent system are unlikely to generate the necessary innovation, much of malaria R&D is now taking place through public–private product development partnerships (PDPs), which receive significant philanthropic, public, and private investments [22]. In contrast to classic private-sector product development, however, the PDPs have an explicit objective of jointly achieving affordability and innovation suited to developing country contexts. PDPs are redefining the roles of public and private sectors and promoting new expectations for the development of health technologies as global public goods.

Experience with malaria offers several lessons for R&D in other health areas. First, investments in human capital are essential but take many years to bear fruit. Here the long-term commitment of the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR) and the recent £30 million commitment from the Wellcome Trust for research capacity building in Africa should be noted [23]. Nevertheless, greater training in laboratory sciences, health economics, management, program evaluation, and implementation research are clearly needed. Capacity-building of developing country researchers and research organizations (e.g., universities, public research institutes) should receive greater emphasis and be scaled up today. Second, considerations of access to products should be built into R&D processes from their inception. The WHO Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Property, approved at the 2008 World Health Assembly (WHA), is an important contribution to rethinking the governance of the R&D system, and merits the constructive engagement of all concerned parties [24].

Implementation and Delivery

As the essential link between global actors and local populations, national health systems are a critical part of the global health system. Health systems must accomplish multiple challenging tasks. These include: providing preventive and primary care services; developing a health workforce; devising equitable financing arrangements; regulating the private sector; and leveraging vertical programs (such as malaria control) to strengthen, rather than distort, the overall health system (“diagonalization” [25]) ([4]).

Health system performance varies widely but the reasons for this variation remain poorly understood. For example, Eritrea, Ethiopia and Rwanda have reduced malaria-related morbidity and mortality dramatically [26],[27]. Eritrea, for one, credits the RBM strategy and community health workers as key components of their approach [28]. However, it is unclear why, largely using the same strategies recommended to all endemic countries, others were less successful. Recent analyses of health systems performance point to leadership, community involvement, district-level focus, use of data to set priorities and track progress, and prioritizing equitable access as key factors that have enabled significant improvements in health outcomes in some countries [4],[29]. Even when public sector delivery capacity is weak, some countries have still managed to expand primary health care coverage and improve childhood survival by engaging the private for-profit as well as nonprofit sectors [29]. These non-state actors can energize national health systems by sharing knowledge of how better to achieve efficiency, outreach, and user satisfaction. A comprehensive operational and policy research agenda is needed to understand fully which policies and practices best strengthen national health systems [30],[31].

Monitoring, Evaluation, and Learning

Reliable information on the impact of health programs is critical to setting priorities, measuring efficacy, and maintaining global support for any intervention. Yet the global health system currently poorly manages monitoring and evaluation (M&E). There is no consensus on key questions regarding who should be responsible for M&E, how it should be carried out, how available the information should be, and how it should be used. National and subnational organizations for conducting M&E and promoting critical learning are relatively weak, and incentives for strengthening them are almost nonexistent.

For example, there remain enormous gaps in knowledge about malaria. Precise annual and seasonal malaria incidence and mortality data, or the percentage of children with fevers that actually have malaria, are unavailable in most endemic countries and districts [28],[32]–[34]. How to mobilize communities to make full use of bed nets, artemisinin combination therapies (ACTs), and indoor spraying remain critical research issues. With increasing funds being expended on programs, it is shortsighted that so little is spent on operational research, on learning what works in specific contexts and how best to engage communities to use the tools available [35]. An essential step toward sufficient investment in M&E is to acknowledge and plan for its costs, both in dollars and, more importantly, in the limited time available from experienced managers and researchers. This research is vital, yet ironically it is too rarely funded by major donors nor requested by implementing countries.

M&E should be an integral part of all program planning, yet it is too often an afterthought. Furthermore, effective M&E of programs and interventions, as well as learning from experience, requires that M&E efforts achieve technical credibility, maintain legitimacy (i.e., general acceptance of their authority), and produce knowledge that is salient for end-users. These three objectives often compete directly with one another [36]. For example, there is often tension between the goal of producing data for internal learning and that of monitoring by outside parties (e.g., higher-level officials or donors). When evaluation data are linked to funding, as in currently favored “performance-based funding,” the accuracy of the data provided may diminish. It may be necessary to create institutional “safe spaces” where failures can be divulged to encourage genuine learning rather than used to assign blame for underperformance [37],[38].

Similarly, at the global level, all countries provide health statistics to WHO, but the quality and validity of these data vary greatly. Yet WHO is a producer, repository, and evaluator of evidence, and simultaneously a political organization representing 193 countries, and so it will be particularly difficult for the organization to meet the demands for saliency, credibility, and legitimacy. Academic researchers, who also play a critical role in M&E, face a contrasting set of difficulties. While they may achieve technical credibility, it is more challenging to achieve political legitimacy and ensure that the knowledge produced is salient to end users and policy-makers.

Several new organizations are addressing some of these issues. For example, the Institute for Health Metrics and Evaluation [39] and the WHO-hosted Health Metrics Network [40], both funded in part by the Bill & Melinda Gates Foundation, were recently created to develop methods to acquire, analyze and disseminate relevant and reliable information on burden of disease and global health. There are promising models, some country-based such as the India Program Evaluation Network coming out of the International Clinical Epidemiology Network (INCLEN) [41] and the India network, IndiaCLEN [42], others international, such as the Southern-led INDEPTH epidemiological network [43] and the Cochrane Collaboration [44]. The challenge is not only to secure the evidence, but also to have the political and procedural legitimacy that, to date, few organizations other than the UN agencies have been chartered to provide.