Who should set the global health priorities?

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 says that an increasing challenge in the governance of global health research funding is agenda-setting.

Her essay refers to a phenomenon called "multi-bi financing", the practice by donors of routing funding earmarked for specific sectors, themes, countries, or regions through multilateral agencies such as the World Health Organization (WHO) and the World Bank. It has also led to the emergence of new "multistakeholder initiatives" such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the GAVI Alliance.

Devi Sridhar writes 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 much narrower 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, comments: '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.'

She also highlights her concern over the constitutional organisations that provide governance for agenda-setting. While member states make up the boards of traditional multilateral organisations, the Global Fund and GAVI have representatives of the public sector and donor groups sitting on their boards. Dr Sridhar concludes that these new initiatives have a wider set of stakeholders that includes none-state institutions, narrower problem-based mandates, financing based on voluntary contributions, no country presence, and legitimacy based on effectiveness and not process.

Dr 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.'