Editorial
Who runs global health?
The past two decades have seen dramatic shifts in
power among those who share responsibility for leading
global health. In 1990, development assistance for
health—a crude, but still valid measure of influence—was
dominated by the UN system (WHO, UNICEF, and UNFPA)
and bilateral development agencies in donor countries.
Today, while donor nations have maintained their relative
importance, the UN system has been severely diluted. This
marginalisation, combined with serious anxieties about
the unanticipated adverse effects of new entrants into
global health, should signal concern about the current
and future stewardship of health policies and services for
the least advantaged peoples of the world.
In this issue, Nirmala Ravishankar and her colleagues
show quantitatively what many observers have seen
qualitatively—the rising importance in global health of
non-state and non-UN actors: the Global Fund, GAVI,
World Bank, Gates Foundation, and non-governmental
organisations. While those concerned with the world’s
health will be glad that development assistance for health
has risen from US$5·6 billion in 1990 to $21·8 billion in
2007, they will also be concerned that the influence of
intergovernmental agencies is being crowded out by
donor-driven funding patterns that may not be fully
responding to country needs.
These concerns are not merely theoretical. In WHO’s
first assessment of the effects of global health initiatives
(GHIs, including the Global Fund, GAVI, PEPFAR, and the
World Bank’s Multicountry AIDS Programme) on health
systems, the report card is mixed. It is certainly correct
to say that GHIs illustrate a remarkable international
commitment to diseases affecting millions of people
already living in poverty. Access to medicines, such
as antiretrovirals, has improved. Case detection of
tuberculosis has increased. Coverage of insecticide-
treated bed-nets has risen. There are emerging signs
of some positive benefits in health equity, quality of
services, innovative financing for health, task shifting,
training, community participation, monitoring and
evaluation, and the price of medical products.
But those “positive synergies” have also been
accompanied by negative effects. We already know, for
example, that GAVI’s immunisation services support
has encouraged over-reporting of vaccination success
by recipient countries. The true situation in countries
www.thelancet.com Vol 373 June 20, 2009
seems to be compounded by further problems. A team of
scientists across 30 nations, and including WHO, UNICEF,
UNAIDS, GAVI, the Global Fund, and the World Bank, now
reveal several adverse effects of GHIs on health systems.
Some of the most troubling harms include steepening
inequalities in health services, reduced quality of services
because of pressures to meet targets, decreases in
Allan Gichigi/IRIN
domestic spending on health, misalignment between
GHIs and country health needs, distraction of government
officials from their overall responsibilities for health, the
See Articles page 2113
creation of expensive parallel bureaucracies to manage
See Health Policy page 2137
GHIs in countries, the weak accountability of a rapidly See Articles Lancet 2008;
expanding GHI-funded non-governmental sector, and 372: 2031–46
increased burdens on already fragile health workforces.
A further important finding by the WHO team is that
GHIs have not taken the independent evaluation of their
programmes sufficiently seriously. For initiatives that have
many well-known researchers on their boards and advisory
committees, this is an extraordinary failure. GHIs have
been flying blind, apparently indifferent to knowledge
about the effects of their investments in countries.
The WHO’s Maximising Positive Synergies Collaborative
Group makes five important recommendations: health
systems strengthening needs to be a higher priority
for GHIs; targets for GHIs need to include indicators for
health systems; GHIs need to work harder to collect more
reliable information about their effects; and donors need
to increase their financial support of not only GHIs, but
also health systems. A meeting in Venice next week,
drawing together ministers from over 50 countries and
leaders from several major GHIs, will discuss how to
implement these proposals as a matter of urgency.
So who does run global health in 2009? The answer
is a multiplicity of actors, old and new. But newer
entrants should be careful what they wish for. WHO
remains compellingly important to global health, for
all its problems and relatively declining financial power.
The health agency’s influence might have been eroded
during the past two decades. But thanks to WHO’s
technical leadership (forcing evaluation back onto the
global agenda) as well as mistakes by GHIs (ignoring
their own performance), the need for a strong, well-
funded, and politically supported WHO has become a
much sharper and convincing argument today than for
many years. ■ The Lancet
2083