IHP+: little progress in accountability or just little progress?

A review and analysis of accountability in global health funding, research collaborations and training: towards conceptual clarity and better practice

INTRODUCTION

Accountability is a complex idea to unpack and involves different processes in global health practice. Calls for accountability in global health would be better translated to action through a better understanding of the concept and practice of accountability in global health. We sought to analyse accountability processes in practice in global health funding, research collaborations and training.

METHODS

This study is a literature review that systematically searched PubMed and Scopus for articles on formal accountability processes in global health. We charted information on processes based on accountability lines ('who is accountable to whom') and the outcomes the processes were intended for ('accountability for what'). We visualised the representation of accountability in the articles by mapping the processes according to their intended outcomes and the levels where processes were implemented.

RESULTS

We included 53 articles representing a wide range of contexts and identified 19 specific accountability processes for various outcomes in global health funding, research collaborations and training. Target setting and monitoring were the most common accountability processes. Other processes included interinstitutional networks for peer checking, litigation strategies to enforce health-related rights, special bodies that bring actors to account for commitments, self-accountability through internal organisational processes and multipolar accountability involving different types of institutional actors. Our mapping identified gaps at the institutional, interinstitutional and broader system levels where accountability processes could be enhanced.

CONCLUSION

To rebalance power in global health, our review has shown that analysing information on existing accountability processes regarding 'who is accountable to whom' and 'accountability for what' would be useful to characterise existing lines of accountability and create lines where there are gaps. However, we also suggest that institutional and systems processes for accountability must be accompanied by political engagement to mobilise collective action and create conditions where a culture of accountability thrives in global health.

Assessing implementation mechanisms for an international agreement on research and development for health products

The Member States of the World Health Organization (WHO) are currently debating the substance and form of an international agreement to improve the financing and coordination of research and development (R&D) for health products that meet the needs of developing countries. In addition to considering the content of any possible legal or political agreement, Member States may find it helpful to reflect on the full range of implementation mechanisms available to bring any agreement into effect. These include mechanisms for states to make commitments, administer activities, manage financial contributions, make subsequent decisions, monitor each other's performance and promote compliance. States can make binding or non-binding commitments through conventions, contracts, declarations or institutional reforms. States can administer activities to implement their agreements through international organizations, sub-agencies, joint ventures or self-organizing processes. Finances can be managed through specialized multilateral funds, financial institutions, membership organizations or coordinated self-management. Decisions can be made through unanimity, consensus, equal voting, modified voting or delegation. Oversight can be provided by peer review, expert review, self-reports or civil society. Together, states should select their preferred options across categories of implementation mechanisms, each of which has advantages and disadvantages. The challenge lies in choosing the most effective combinations of mechanisms for supporting an international agreement (or set of agreements) that achieves collective aspirations in a way and at a cost that are both sustainable and acceptable to those involved. In making these decisions, WHO's Member States can benefit from years of experience with these different mechanisms in health and its related sectors.

Improving the impact of sexual and reproductive health development assistance from the like-minded European donors

Aid from Denmark, Finland, Germany, Netherlands, Norway, Sweden and UK provides essential support for sexual and reproductive health and rights. Recent research, however, has revealed conflicting values in how their aid is programmed, resulting in a reduction in both quantity and quality of support provided. The strong commitment of these donors to country ownership has, in practice, invested decision-making primarily with developing country governments, with civil society playing a much weaker role. In most countries, strong civil society organizations are needed for effective advocacy of sexual and reproductive health and rights and health service delivery, and the restricted role of this sector has slowed progress towards universal access to reproductive health. The research documented also that these donors' respect for the autonomy of multilateral health agencies has resulted in some reluctance to encourage more attention to SRHR. In addition, their commitment to "impact" has not translated into the incorporation of relevant and practical outcome measures by which to assess the results of their investments. Almost 80% of the money they earmark for sexual and reproductive health and rights goes to UNFPA, underscoring its critical role. This article recommends donor support for a stronger civil society role in the design, implementation and evaluation of SRHR funding; strengthening civil society so that it can successfully undertake this role; use of better outcome measures to assess impact; and active support for UNFPA to implement the recommendations of recent external reviews.

The Health Systems Funding Platform: Is this where we thought we were going?

BACKGROUND

In March 2009, the Task Force for Innovative International Financing for Health Systems recommended "a health systems funding platform for the Global Fund, GAVI Alliance, the World Bank and others to coordinate, mobilize, streamline and channel the flow of existing and new international resources to support national health strategies." Momentum to establish the Health Systems Funding Platform was swift, with the World Bank convening a Technical Workshop on Health Systems Strengthening (HSS), and serial meetings organized to progress the agenda. Despite its potential significance, there has been little comment in peer-reviewed literature, though some disquiet in the international development community around the scope of the Platform and the capacity of the partners, which appears disproportionate to the available information.

METHODS

This case study uses documentary analysis, participant observation and 24 in-depth interviews to examine the processes of development and key issues raised by the Platform.

RESULTS

The findings show a fluid and volatile process, with debate over whether ongoing engagement in HSS by Global Fund and GAVI represents a dilution of organizational focus, risking ongoing support, or a paradigm shift that facilitates the achievement of targeted objectives, builds systems capacity, and will attract additional resources. Uncertainty in the development of the Platform reflects the flexibility of the recently formed global health initiatives, and the instability of donor commitments, particularly in the current financial climate. But implicit in the conflict is tension between key global stakeholders over defining and ownership of the health systems agenda.

CONCLUSIONS

The tensions appear to have been resolved through a focus on national planning, applying International Health Partnership principles, though the global financial crisis and key personnel changes may yet alter outcomes. Despite its dynamic evolution, the Platform may offer an incremental path towards increasing integration around health systems, that has not been previously possible.

Aid alignment for global health research: the role of HIROs

The lack of a mechanism that aligns financial flows for global health research towards public health priorities limits the impact of health research on health and health equity. Collaborative groups of health research funders appear to be particularly well situated to ameliorate this situation and to initiate discussion on aid alignment for global health research. One such group is the Heads of International Research Organizations (HIROs), which brings together a large number of major government and philanthropic funders of biomedical research. Surprisingly, there is hardly any information publicly available on HIROs' objectives, or on how it aims to achieve more harmonization in the field of research for health. Greater transparency on HIROs' objectives and on its current efforts towards addressing the gap between global health research needs and investments would be desirable, given the enormous potential benefits of more coordination by this group.