Improving the engagement of global health initiatives with country health systems, including in fragile and shock-prone settings
The number and role of global health initiatives has been growing over the last 25 years, with the Global Fund for AIDS, TB and Malaria (GFATM) and the Global Alliance for Vaccination (GAVI) alone providing 14% of development assistance for health in recent years. Their contribution to essential disease programmes has been significant but concerns have been expressed for some time over their potential distortion of health systems, given their very specific focus and operating modalities, as well as a potential lack of match to the changing disease burden.
In response to these concerns, the Future of Global Health Initiatives (FGHI) [opens new tab], chaired by health leaders from Kenya and Norway and supported by the Wellcome Trust, undertook consultations and a consensus-building exercise in 2022-3 to address current and future challenges facing GHIs in contributing to countries’ Universal Health Coverage (UHC).
Pathways to impact
A ReBUILD team from Queen Margaret University (QMU), led by Professor Sophie Witter and including Natasha Palmer, Maria Bertone and Giulia Loffreda, joined with the University of Geneva and colleagues from Stellenbosch University, South Africa, Aga Khan University, Pakistan, and the Cheikh Anta Diop University, Senegal, to undertake a series of global, regional and national consultations and draft a research report to inform the FGHI consensus-building process. Although this research process was funded by the Wellcome Trust, the engagement over the past 18 months was much more extensive than the funded time, with ReBUILD supporting some of the researchers’ time to ensure that the research uptake continued after July 2023.
The report (read it on the FGHI website), led by Professor Witter, documented the strengths and weaknesses of the GHIs, particularly from a country perspective, as well as examining the factors that influence the space for reforms. It included a draft vision (see below), principles for engagement and sets of reform recommendations grouped under six core themes. It was discussed at a forum convened by the team in Addis Ababa in June 2023 (more on that on the FGHI website) to discuss various reform scenarios with national, regional and global stakeholders The final research findings were presented by the research team at public webinars in August and September 2023, and were discussed at FGHI research and learning task team meeting, African regional fora in the autumn, as well as the Wilton Park dialogue in October (more on the FGHI website) and the IDSI conference in November. During the whole research and research uptake process, we worked closely with FCDO advisors engaged in a linked exercise of reviewing the functioning of the GHIs from FCDO’s perspective.
Findings were picked up and magnified by other groups, including, for example, in blogs by CGD and articles on improving aid effectiveness [opens new tab]. A panel on the political economy of reforms to the GHIs, chaired by Professor Witter, has been accepted for the Health Systems Research symposium in November 2024, and will include country researchers and the WHO focal person for the FGHI follow up.
Vision statement
(from Witter, S. et al., 2023, Reimagining the Future of Global Health Initiatives. Final Report for Wellcome Trust/Government of Norway)
A global health system where all actors, including GHIs, contribute effectively to the achievement of country-led UHC and hence equitable population health and wellbeing. This means that all actors, including GHIs, plan, fund, evaluate and account for their funds and programmes to national governments in a coherent and integrated way, working in synergy with other global health actors and based on their comparative advantage, countries’ priorities and needs, and the imperative to build country capacity to sustain UHC (including PHC) through strong and resilient health systems.
In terms of roles, this vision implies that:
• Implementing countries take increasing responsibility for essential, cost-effective interventions as and when they have the capacity and finance to do so
• GHIs support countries in this effort, embedding sustainability, supporting affordable commodities, and setting clear trajectories towards transition; and
• Donors shift accountability for delivery more to countries, demonstrating a higher risk appetite and accepting broader PHC and UHC results
Impact
The process of consensus building culminated in the Lusaka Agenda (more on the FGHI website), which committed GHIs and other global health actors (bilateral funders that sit on their boards and fund the GHIs, also national governments and civil society partners) to strengthen their contribution through five key shifts. These were to:
1. Make a stronger contribution to primary health care (PHC) by effectively strengthening systems for health
2. Play a catalytic role towards sustainable, domestically-financed health services and public health functions
3. Strengthen joint approaches for achieving equity in health outcomes
4. Achieve strategic and operational coherence
5. Coordinate approaches to products, research and development (R&D), and regional manufacturing to address market and policy failures in global health
These shifts were supported by eight areas of agreed short term changes, to be undertaken over one to three years, as well as a proposed series of next steps.
From January 2024, a working group chaired by representatives of Ghana, Canada and Amref Health Africa has been working to support and coordinate implementation (more on the FGHI website). Governance mechanisms, including at the regional level, led by the African Union and CDC, are under discussion, and the GHI boards are discussing follow up actions at their spring 2024 meetings.
There is also ongoing work, led by Professor Witter in collaboration with CGD, to develop a tracker of progress indicators to ensure that there is accountability from the GHIs for follow up action.
Other progress which has been sparked by the FGHI process (which is still ongoing) includes a working group convened by WHO to develop and get buy-in for health system indicators in order to better plan and track health system strengthening interventions by GHIs and others. Natasha Palmer of QMU is represented in that group.
The process of implementation of changes is beginning but there is early promise that some significant structural and operational improvements to the main GHIs that are funding country level health investments will ensue. These should reduce the costs to countries of engaging with multiple GHIs, ensure that investments are more coherent (less fragmenting) of local health platforms and priorities, and support a more sustainable and country-led UHC. This is particularly valuable in fragile and shock-prone settings where dependence on GHIs is higher and likely to be longer lasting.
Further information
- Witter, S. et al. (2023) Reimagining the Future of Global Health Initiatives. Final Report for Wellcome Trust/Government of Norway [Opens new tab]
- The Lusaka Agenda: Conclusions of the Future of Global Health Initiatives Process. December 2023. FGHI secretariat [Opens new tab]