What is it with shapes and global development? Seems a week doesn’t go by without someone proposing a new one. I wish I worked in sustainable development – they get food-inspired shapes like doughnuts. In public health you just get triangles. At least you used to. Now we have a proposal to consider from three well-known global health scholars: Mark Dybul, Peter Piot and Julio Frenk. They want to re-shape global health. They think it’s a radical proposal. Here’s what I think.
2000-2010: The decade of global health
“The opening ten years of the 21st century arguably were the decade of global health”
Arguably. Everything is arguable. We can describe health as ‘global’ to the extent that an ill-health-causing phenomenon affects us all (not necessarily equally) irrespective of where we are on the planet. So, climate change, for example, or sovereignty, or capitalism are global health problems. Because global health is not defined by how much money donor countries decide to give to certain health problems, a decade receiving more money for (some) health is no more ‘global’ than a decade (before or after) receiving less money.
From paternalism to shared responsibility and mutual accountability
“The rapid expansion in global health was part of a broader conceptual movement that created core principles for the use of resources in a new era in development”.
Let’s be clear: the ‘core principles’ – shared responsibility, mutual accountability, country ownership – are an extension of paternalism not a shift away from it. That’s not all that surprising: donors don’t like to just give their money away (a reality that has done for the Global Fund). Later on in their article, Dybul, Piot and Frenk worry that the recipients of donor money aren’t spending enough of it on health. Tell me if this isn’t paternalistic:
“It is essential that all countries contribute financial resources to the health of their own people. The very low levels of national financing for public health in certain countries, including emerging economies, are not acceptable. And nothing is more likely to halt interest in global health than recent data that some governments have treated increased international resources for health as an opportunity to redirect their own funding to other areas”.
I won’t go into the data and debate around this issue – you can read it here, here, and here. My general point is that the principles exalted by the authors (shared responsibility, mutual accountability, country ownership) perform a specific function: namely, to obscure the self-interest of the donors that devised them. You can imagine, if you wish, that relations between rich and poor are defined by such principles, but you’re fooling yourself if you do.
Let’s take a closer look at one of these principles: shared responsibility. According to the authors: “key to shared responsibility is leadership and strategic direction”. Is it? No, it isn’t. First and foremost, responsibility is individual responsibility, which can evolve into collective responsibility. It is fundamentally not about leadership. But also key to responsibility is doing what you say you’re going to do. It builds trust. If there’s trust, then there’s more chance you’ll actually do what you said you were going to do – something leaders are extremely bad at doing (see here, or here for example).
But don’t worry, Dybul, Piot and Frenk have a plan for getting countries to spend the money they are given on the things that donors want them to spend it on. They call it “transition planning for financial responsibility” – yes, I know, gripping. The authors think it’s the real deal.
“It is difficult to conceive of a more effective way to create shared responsibility and mutual accountability that would transform health care”.
Not that difficult actually.
First, we shouldn’t start from the assumption that we have sufficient knowledge, experience, insight, or wisdom to design and implement a framework for global health without, apparently, any consultation from anyone else, particularly not from those recipients of our largesse. Has anyone actually asked the authors if they could re-shape global health for us? Here’s a radical idea: ask developing countries to come up with their own framework for what they want the world to look like.
Second, recall that the last half-millennium of European intervention has been premised not on a sense of shared responsibility but on the principle of kicking away the ladder – enriching ourselves and then preventing others from enjoying the opportunities for wealth creation that we have enjoyed. Recall also that ‘shared responsibility’ – lets just call it responsibility – is a cross-cutting theme. This means that we have a responsibility to join the dots between what we give to other countries to support their health systems and what we take away again with development strategies such as agricultural subsidies or debt servicing.
And third, don’t start from the premise that countries receiving development assistance don’t know how best to spend the money they receive. There are lots of reasons why money for health isn’t spent on heath, one of which is that recipient governments know all too well how unpredictable donor funding can be, and they are (sensibly) insuring themselves against a fall.
A rational global health strategy?
With global health leaders having demonstrated no rational, joined-up, thinking about global health throughout the so-called golden years, our esteemed trio now think it’s time to get rational. One of the great mysteries of public health is how so much policy is influenced by so little evidence. Ideas, it seems, are simply plucked out of a hat, announced to the world, and then left to stagger into a ditch somewhere. When sensible people call on their governments to get rational – on drug policy, for example – they are sacked.
The problem with rationality is that it is always trumped by political ideology. So, for example, if a government wanted to privatise its country’s health service it would, regardless of the evidence showing that that would not be in the best interests – or health – of its electorate. Furthermore, as Ted Schrecker put it recently, rationalism neglects “the power of actors standing to gain from the continuation of business as usual”.
Nevertheless, rationality is what the authors want to bring to global health policy. The past irrationality stemmed from a “focus on specific diseases” (like HIV/AIDS) that “has imposed and exposed fault lines in delivering services in places where many suffer from multiple health issues at the same time”. Yes, ok, we’ve heard this vertical-horizontal debate before. I would just note that PEPFAR, which Dybul led for quite a few years, had its part to play in promoting a vertical, single-issue health agenda. But let’s not dwell on that. What the authors now propose is an “integrated approach focused on the health of a person and community”. Great, sounds good to me. So, how do we get there?
The sound of one idea clapping: a Bretton Woods agreement for global health
“It is time for a Bretton Woods-style agreement to guide a new international health strategy and rationalize its structure”.
In the mosh pit of global health policy only certain ideas survive. Academics spend a happy time trying to understand which ones prevail. There are currently a lot of ideas swirling around, jostling for purchase in time to influence the RioPlus20 agenda. Hopefully, we’ll learn the lessons of the MDGs and not have another set of development goals. Dybul, Piot and Frenk have a ‘big’ idea – a Bretton Woods agreement for global health.
There isn’t much detail in the article about what a Bretton-Woods agreement for global health would entail. It would, however, be led by the G20 “with the active engagement and leadership of the emerging economies and other middle- and low-income countries”. The aim of this agreement would be “to rationalize the institutional structure of global health”. If we weren’t being charitable, we might point out that the G20 is not an obvious choice to lead the rationalization process. Devi Sridhar has blogged here about some of the problems facing a G20-led approach to global health, highlighting weak representation, low capacity and lack of political will as problems that the group would have to overcome.
Actively engaging “emerging economies” is also a strategy built on quick sand, not least because the rate of those economies’ growth is rapidly slowing down. And yet the authors see this politically disparate group of countries as essential for sustainable financing:
“To achieve sustainable financing, the direct and deep engagement of emerging economies and other middle- and low-income countries is essential”.
Dybul, Piot and Frenk need to step out of the health silo for a minute and take a look around them. To achieve sustainable financing, banks need to be regulated and transparent in their investments. Governments need to re-introduce the Glass-Steagall Act immediately as one way of separating casino and savings banks. That goes to the surface of the matter, if not the heart. To go to the heart of the matter requires a fundamental rethink of socio-economic relations. We have an opportunity to do that now, to look honestly at how the original role of the Bretton Woods institutions evolved from reconstructing European economies during the the 1940s-60s to deconstructing ex-colonial economies during the 1970s-90s in the name of neoliberal economics – immiserating millions in the process . I think Pinky’s perspective is spot on here.
The Pinky Show: Banked into submission: the globalizationists guide to developing poverty
“As we approach the post-MDG era, now is the time for a new framework to establish an accelerated trajectory to achieve a healthy world.”
Dybul, Piot and Frenk have a new framework for us, the basic principles of which are: focusing on the health of persons, but also communities (yes, I know, you may be wondering ‘you mean, we haven’t been focusing on these groups?)’; health as a public good; and human rights. These principles aren’t developed further. Shame. Here’s an interesting question to think about in relation to health as a public good: who provides it? The Bretton Woods financial institutions – the World Bank and the IMF? Read Rick Rowden’s book on the IMF to find out why that is extremely unlikely. Unfortunately, it is precisely these institutions that the authors have in mind as principal financiers of their re-shaped globe.
The new principal financiers of global health
They give us two options: create something new or reform the World Bank and/or the Global Fund. The authors are open to ideas for the ‘something new’ category, but the bottom line is that donors don’t trust country-level pooled-funding anymore and might be more attracted to a globally-pooled fund. In fact, one gets the sense that the ‘something new’ category isn’t really an option on the table. Later on, for example, we hear a call for ”a certain degree of healthy pluralism and competition…that keeps principal financiers and multilateral and bilateral partners in the game”. So, nothing new, in fact.
To reiterate, what we really need are “innovation and competition”. And I bet you can guess where that’s going to lead us? Not surprisingly, the authors are keen to emphasise the importance of the private sector – hardly the champions of innovation or competition, as the pharmaceutical industry’s opposition to generic drug manufacture makes clear. And they’d like to see the private sect..sorry, I mean “greater engagement of nonhealth stakeholders” to “maximize [the] key convening authority” of the World health organisation.
“The key role of the private sector is finally being recognized as an important element of global health and development. The private sector could play a particularly useful role in rationalizing the structure of global health”.
Unfortunately, there is not further elaboration on this, but perhaps they were thinking of the sugar industry’s strategy for health (the subject of an excellent piece of journalism here), or the alcohol industry’s concern for our livers, or the soft-drinks manufacturers’ interest in our teeth, or burger MNCs’ concern about our waistline, or private healthcare providers’ interests in our wallets? The private sector has NO useful role in structuring global health, but it is doing it nonetheless – to our collective detriment.
You’re ideas are unrealistic, my ideas are big
The authors end with some puzzling mixed-messages: “The era of advocates demanding unachievable new commitments, and organizations and leaders acquiescing with the full knowledge that they are unreachable, must end”. But not, presumably, until you’ve read and acted upon the ideas presented in the authors’ paper? “Repeatedly setting unachievable targets and failing to meet them shatters a sense of accountability and perpetuates commitments that no one intends to keep. But that does not mean big ideas should not be pursued”. Because, if it did, then I guess there would be no reason for us to take your ‘big ideas’ seriously, would there?
A Bretton Woods agreement for global health?
So, what do we have? The authors say they are presenting “a radical vision”. As a rule of thumb, if you have to describe your idea as radical it probably isn’t. But take time to look at the detail. Maybe you will see something good here. All I can see are further retrenchment of paternalistic development principles, the same global health financiers financing global health (albeit now with more control over what and how that money is spent), and a greater role for the private sector in global governance.
We simply don’t have time for this ‘big idea’.