Risk that global health funding is ‘made in the market place and not by communities’
25 September 2012
There is a risk that the setting of priorities for global health will be made in the market place rather than in the community that has to live with the consequences, argues an Oxford University researcher. In an Essay published in PLOS Medicine, Dr Devi Sridhar argues that since the priorities of funding bodies largely dictate what health issues and diseases are studied, a major challenge in the governance of global health research funding is agenda-setting, and this in turn is a consequence of a larger phenomenon called “multi-bi financing”.
Multi-bi financing refers to the practice of donors choosing to route funding—earmarked for specific sectors, themes, countries, or regions—through multilateral agencies such as the World Health Organization (WHO) and the World Bank, and to the emergence of new “multistakeholder initiatives” such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the GAVI Alliance.
The researcher argues that driven by widespread concerns about HIV/AIDS, maternal mortality and flu pandemics, the past two decades have witnessed an exponential growth in health financing. But while traditional multilateral organisations like WHO have broad mandates, institutions like the Global Fund to Fight AIDS and the GAVI Alliance (which sets out to increase access to immunisation in poor countries) have narrowly defined mandates that are problem-focused.
Dr Sridhar, a University Lecturer in Global Health Politics at the Blavatnik School of Government and in the Department of Politics and International Relations, commented: ‘Multi-bi financing has resulted in exponential growth in attention and financing for issues like HIV/AIDS where funding is estimated at $10 billion (2007) while areas like malnutrition with funding estimated at $300 million (2007) and diabetes struggle.’
Another issue highlighted is governance: while traditional multilateral organisations have boards solely comprised of member states, the Global Fund and GAVI have boards on which sit representatives of the public sector and the Bill & Melinda Gates Foundation. Dr Sridhar concludes that these new multistakeholder initiatives have five distinct characteristics: a wider set of stakeholders that include none-state institutions, narrower problem-based mandates, financing based on voluntary contributions, no country presence, and legitimacy based on effectiveness, not process.
Sridhar adds: ‘On the face of it, the rise in funding and the plurality of institutions in global health looks like increased support for multilateral cooperation. The WHO programme budget has doubled. The World Bank’s lending for health has trebled. But there is the risk that multi-bi financing may create mechanisms that permit donors to favour short-term gains over longer term public health goals.
‘Another risk is that this financing model will erode global capacities to create, collate and disseminate information, the cornerstone of research. However, on the positive side, one major impact of multi-bi financing has been to shine a clear light on how and where multilateral institutions, such as the World Bank and WHO, might do better.’
According to the article, within WHO the two-year budget has more than doubled in the past decade from US$1.647 billion in 1998-99 to US$4.227 billion in 2008-09. Most of the growth, however, has been in extra-budgetary funding, which has risen from 48% in 1998-99 to 77% in 2008-09. Extra budgetary funding is used for the purposes decided by individual donors (or groups of donors) while core funding is decided by all member states in the World Health Assembly.
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